The Early Diagnosis Of The Acute Abdoman Eighth Edition

THE EARLY DIAGNOSIS OF THE
ACUTE ABDOMEN

Fio 1 — Drawing to show the parieCol mueeics of the abdomen whieli bjr
tbeir rigidity, immobibtjr, and tenderness, give important help m
diagnosis of the acute abdomen (On the right aide the twelfth
dorsal nerve, and the ilio hn>oE'^*tnc.ilio-uigumaI. external cutaneooa,
and genito crural nervee are indicated }

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OXFORD MEDICAL PUBLICATIONS

THE EARLY DIAGNOSIS

OF

THE ACUTE ABDOMEN

ZACHARY COPE

B A.. Nf.D., M.S. Lond , F.R.C.S. Eng.

SCtOZOK TO 1ST HiHTS >IO»PITtb| PtPDISOTOT. eCVIOft •CPStOW TO THE SOlSlfCSEOKE
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EIGHTH EDITION

OXFORD UNIVERSITY PRESS
LONDON ; HUMPHREY MILFORD

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FtritEdilton .... 1921

Steond Edition .... 1923

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Third Edition .... X925

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Fourth Edilwn .... 1027

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Sixth Edition .... 1932

Stvtnth Edition .... 1935

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Eighth Edition . . . 1910

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PREFACE TO THE EIGHTH EDITION

The alterations in this edition consist of many
small verbal changes and additions and the in-
clusion of three more X-ray photographs. It would,
in the author’s opinion, be unwise to make any
serious alteration in a book whicli, judging from its
reception by the profession, still appears to meet
a real need.

ZACHARY COPE.

I.ONDOK, W.l
JanwTjj 1940

Extract irom the

PREFACE TO THE FIRST EDITION

All -who have had much experience of the group
of cases knoivn generally as the acute abdomen will
probably agree that in that condition early diagnosis
IS exceptional There are still many who do not
appreciate to the full the significance of the earlier
and less flagrant symptoms of acute abdominal
disease, who regard an increased frequency of the
pulse and rigidity of the overlying abdominal
muscles as necessary accompaniments of the early
stage of appendicitis, or find it hard to believe that
a patient ^vith a non distended abdomen and normal
pulse and temperature can be the victim of a
perforated gastric ulcer

It would appear, therefore, that there is room
for a small book dealing solely with the early diag-
nosis of such cases, for there is little need to labour
the truism tliat earlier diagnosis means better
prognosis Though the present attempt to supply
the deficiency may be inadequate, the author has
at least endeavoured to assist the reader to attain
a correct judgment in the evaluation of the various
puzzling symptoms present in urgent abdominal
disease

Few references are inserted and no bibliography
IS appended ; for whilst the writer readily acknow-

X PREFACE TO THE FIRST EDITIOX

ledges the great debt which he owes to the teaching
of such leaders as ^lurphy, Jlojniihan, Rutherford
Morison, Maylard, and many others, it has been his
aim to put down nothing which 1ms not been fre-
quently confirmed and demonstrated in his own
experience.

At the same time he has introduced many diag-
nostic points which he believes have either never
previously been recorded or to w'hich insufficient
attention is usually paid. In the former category
may be mentioned the localizing diagnostic value
of phrenic shoulder-pain, the obturator test, and the
test for differentiating between pain of thoracic
and abdominal origin ; whilst in the latter the
area of hyperjesthesia caused by a distended in-
flamed appendix, the pathognomonic axillary area
of liver resonance m cases of perforated ulcer, the
psoas-extension test, and the confusing significance
of testicular pain, serve as examples.

ZACHARY COPE.

Lovno'f
Juris 1921

CONTENTS

CHAPTER I

The Pbinciples of Diagnosis in Acute Abdominal

Disease ... ... 1

CHAPTER 11

Method of Diagnosis: (I) The History . . 21

CHAPTER HI

Method of Diagnosis : (II) The Examination of

THE Patient 35

CHAPTER IV

Appendicitis . . ... 52

CHAPTER V

The Differential Diagnosis of Appendicitis . 74

CHAPTER VI

Perforation of a Gastric or Duodenal Ulcer,

Acute Pancreatitis 94

CHAPTER VII

Acute Intestinal Obstruction .... 118

CHAPTER VIII

Intussusception. 133

CHAPTER IX

Cancer of the Large Bo^vEL — 'V olvulus . . 147

CONTENTS

XU

CHAPTER X

The Early Diagnosis of Strangulated and

Obstructed Hernia 1S5

CHAPTER XI

Acute Abdominal Symptoms in Pregnancy and

THE Puerperium 1C3

CHAPTER XII

Ectopic Gestation 171

CHAPTER XIII

CnoLEcysTiTis and Other Causes of Acute Pain
IN THE Rigut Upper Quadrant of xue Aboo*

MEN 180

CHAPTER XIV

The Coucs 19 i

CHAPTER XV

The Early Diagnosis of Abdominal Injuries . 203

CHAPTER XVl

The Acute Abdomen in the Tropics. . . 211

CHAPTER XVII

Acute Abdominal Disease mitii Genito-Urinary

Symptoms ....... 218

CHAPTER XVIII

The Diagnosis or Acute Peritonitis . • 223

CHiVPTER XIX

Diseases which it ay Simulate the Acute Abdomen 233
Index

LIST OF ILLUSTRATIONS

no

1. Parietal muscles of tlie abdomen . Frontispiece

nan

2. Drawing to show how the obturator intemus may

be irritated . . . . .9

3. Diagram to show the sites on posterior surface of

body to which pain is referred in acute abdominal
conditions ..... . . 11

4. Diagram to show the area to nhich phrenic shoulder-

pain may be referred 13

5. Diagram to show viscera in contact with diaphragm

postenorly . . . 15

6. Diagram to demonstrate method of performing ilio-

psoas test . . . . . 43

7. Diagram to illustrate method of performing the

obturator test . . . . 47

8. Radiogram shomng small-gut distension m obstruc-

tion at ileo csscal junction 50

9 Radiogram of congenital obstruction of the upper

jejunum 50

10. Diagram to indicate the various possible positions of

the 'i ermiform appendix ..... 54

11. Diagram to sho« (1) common positions of initial

referred pam , (2) position of deep tenderness
(nearly always to be elicited when abdominal ^vall
not rigid] ; (8) shaded area to mark out the iliac
triangle of hypenesthesia m cases of appendicitis 58

12. lypes of hyperiBsthesia (to pm stroke) whicJi may

be found m cases of acute and subacute appen-

dicitis . . . .61

13. Diagram to show positions the ciecum may occupy . 71

14. Diagram showing those sites where an abscess result-

ing from appendicitis may sometimes be overlooked. 87

15. Drawing to illustrate Jiow the pelMc peritoneum

may be palpated ...... 99

XIV

LIST OF ILLUSTRATIONS

16 Figure to show significant area of obliteration of

hvei-dullness 101

17 X mj photograph sliowjng free gas betT\een the dia

phragm and the upper surface of the liver in a case
of perforated duodenal ulcer (ante post ) 102

18 X ra> photograph showing free gas between the h%er

and the lateral part of diaphragm in a case of per
forated duodenal ulcer 102

19 Diagram to illustrate the more common abdominal

causes of acute collapse (1) biliary colic , (2)
perforated gastric ulcer, (8) perforated duodenal
ulcer, (4) acute pancreatitis , (5) acute mtestuial
obstruction , (6) acute perforative appendicitis 103

20 Drawing to show ladder pattern of distension (caused

by subacute obstruction of the lower ileum) 128

21 Drawing to show appearance which may be presented

by distension of large bowel 120

22 Types of intussusception 184

28 Diagram to show possible positions of abdominal

tumour ui cases of intussusception 187

24 Diagram to show bow the right iliac fossa is empty

in intussusception 188

25 Series of radiograms taken during the administration
of a barium enema m a case of intussusception
(d) The opaque barium stopped its advance in the
transverse colon at the site of the intussusception
(b) The enema is reducing the intussusception and
filling the ascending colon (c) The intussusception
has been forced back to tbe caicum which is filling
with barium (d) There still remains a small part of
the csccum which does not fill with barium Opera
tion showed this was due to the last unreduced part

of the intussusception 141

20 Diagram of intussusception protruding from the anus 142

27 Diagram of rectal prolapse 1

28 Drawing of common ring type of nncer of the large

bowel I4S

29 X ra> photograph ofsigmoidvohuliissl owing enorm

ous distension of the coil which extends up to the
left hypochondnum 151

00 Drawmg of an umbilical Iiemia embedded in fat 161

51 Diagram to show possible positions of on ectopic
pregnanej

LIST OF ILLUSTRATIONS

32 Diagram of a haematocele (from the front) . .

S3. Diagram of a haimatocele (lateral view )

34. Diagram to illustrate differential diagnosis of condi-
tions simulatmg cholecystitis
85 Diagram to show the common stt« to which pain is
referred in the various forms of colic .

36. Diagram to show method of differentiating between
unilateral pain of thoracic and abdominal ongm .

XV

Pioe

181

183

190

195

235

THE EARLY DIAGNOSIS OF THE
ACUTE ABDOMEN

“ There is surely no greater wisdom than well to time the beginning
and onsets of things ." — ^Bacok, Essay on “ Delays

CHAPTER I

THE PRINCIPLES OF DIAGNOSIS IN ACUTE
ABDOMINAL DISEASE

Before entering on the detailed consideration of
the methods of examination of the various forms of
the acute abdomen, it is well to lay down certain
principles which form the basis of all successful
diagnosis in urgent abdominal disease.

1. The first principle is that of the necessity of
making a serious and thorough attempt at diagnosis
Abdominal pain is one of the most common
conditions which call for speedy diagnosis and
treatment. Usually, though by no means always,
there are other symptoms which accompany the
pain, but in the majority of cases of acute abdominal
disease pain is the main symptom and complaint.
The very terms “ acute abdomen ” and “ abdominal
emergency,” which are constantly applied to such
cases, signify the urgent need for prompt diagnosis
and active treatment. It is common knowledge,
1

2 DIAGNOSIS OF THE ACUTE ABDOMEN

!io\\ ever, that \\ hen confronted ^\ ith a j' ilicnt
suffering great abdominal pain it is often •sery
difficult to be certain as to the exact intra abdominal
lesion -which has gi\en rise to the symptoms In
some instances the urgent need for surgical assist-
ance may be so obvious that the need of transfer
ence of the patient to a surgical centre is clear. In
other cases the observer may, if in doubt, think it
discreet to discuss the problem with a fellow -
practitioner before deciding on any course of action
There are, however, occasions when, with some-
what indefinite symptoms, there may be a tendenc)
to wait for the development of clearer indications, to
see if the condition will not improve spontaneously,
and generally to temporize Tiic last course of
conduct is the least justifiable, for it is a wise plan
always to make a -very thorough attempt to eluci-
date the problem when the patient is seen for the
first time Though m quite a number of cases it is
impossible to be sure of the diagnosis, jet it is
a good habit to come to a decision in cadi case ,
and it will be found that after a short time, proMiled
that no method of diagnosis be neglected, the per-
centage of correct diagnoses will rapidly increase
That there is much room for improvement m tins
direction cannot be gainsaid E\en the operating
surgeon is not free from blame in tins matter, for
the ease and comparatnc safety of operating occa-
sionahj cause him to make a rather perfanctorj
examination of some patients whom from prcMous
experience he judges to be in urgent ncttl of
abdominal section K e\cry surgeon were to make
an exhaustiie attempt at a full diagnosis before
operating, the science of elucidation of acute

THE PRINCIPLES OF DIAGNOSIS 3

abdominal disease would be advanced consider-
ably. There is no field in which diagnosis should
be so precise, since in no class of cases has the
surgeon so great an opportunity of correlating
the symptoms with the pathology of the living.

It is only by thorough examination that one can
propound a diagnosis, and if the early stages of the
disease are to be recognized note must be taken of
the earliest symptoms. The general practitioners
have better opportunities than any other section
of the medical community for observing these early
symptoms, and by patient and painstaking obser-
vation it is possible for them greatly to add to
the stock of common knowledge. To attempt a
diagnosis prevents carelessness, and carelessness in
urgent abdominal diagnosis is close akin to callous-
ness.

It is a truism to say that correct diagnosis
is the essential preliminary to correct treatment,
lyiany and serious results have followed from an
observer jumping to \vrong conclusions which might
easily have been avoided by a real attempt at
clinical differentiation.

Spot-diagnosis may be magnificent, but it is not
sound diagnosis. It is impressive but unsafe. The
deduction and induction from observed facts neces-
sary for the formation of a definite opinion are
good mental discipline for the observer, help to
imprint upon the tables of the mind perceptions
and clinical pictures which can usefully be recalled
in the future, and give a sense of satisfaction which
is only slightly diminished if the resulting opinion
should prove to be incoirect. One often, if not
always, learns more by analysing the process of and

4 DIAGNOSIS OF THE ACUTE ABDOMEN

detecting the fallacy m an incorrect diagnosis than
by taking unction to oneself nhen tlie diagnosis
proves correct.

2. There can be no question that in acute ab»
dominal disease it is of the utmost importance to
diagnose early. Like the business man Iio takes as
his motto “ Do it now the medical man, w hen con-
fronted with an urgent abdominal case, should ha^ e
ever before him the words “ Diagnose now.” Tiie
patient cries out for relief, the relatives are insistent
that something shall be done, and the humane
disciple of wEsculapnis may tliink it Jus first duty
to diminish or banish the too obvious agony by
administering a narcotic Such a policy is often
literally a fatal mistake. Though it may appear
cruel, it is really kind to withhold morphine until
one is certain or not that surgical interference is
necessary, i e until a reasonable diagnosis has been
made. Morphine does little or nothing to stop
serious intra abdominal disease, but it puts an
efficient screen in front of the symptoms The fire
burns, but it is not visible, and sometimes only
when vitality is burnt out is the mistake realized
If morphine be administered, it is possible for a
patient to the happy in tlie belief that he is on the
road to rcco\ery, and in some cases the medical
attendant may for a time be induced to sliarc the
delusi\e hope.

It IS a curious but well known fact that many
who are taken with abdominal pain m tlic daytime
endure till evening before they feel compelled to
send for the doctor. It follows tliat important
decisions often lm\c to be made at night wlien the
phjsRian, weary witli the day’s work, and

THE PRINCIPLES OF DIAGNOSIS 5

perceptions and reasoning faculties somewhat jaded,
is both physically and mentally below his best. The
temptation is often very strong to temporize and
“ see how things are in the morning.” There can
be few practitioners of experience who cannot look
back with regret to one or more occasions when
delay has been fraught with disaster. The waiting
attitude is understandable, but only occasionally
excusable. To suspect an intussusception, to think
that possibly there may be a perforation of a
gastric ulcer, and yet to leave the question undecided
for eight or ten hours, is to gamble with a life. A
delay of two hours in diagnosis may make the differ-
ence between two weeks’ and two months’ illness of
the patient. The fact that the patient comes late
to the doctor is all the greater reason why he
should diagnose as soon as possible. The general
rule can be laid doom that the majority of severe
abdo7ninal 'pains which ensue in patients who have
been previously fairly rceW, and which last as long
as six hours, are caused by conditions of surgical
import. There are exceptions, but the genera-
lization is useful if it serves to call attention
to the need for early diagnosis. It is now
acknowledged by those who are acquainted with
modern surgical results that the best treatment
for perforated ulcers, appendicitis, cholecystitis,
ectopic gestation, and intestinal obstruction is by
surgical intervention. It is also well recognized
that the earlier such cases come to the surgeon the
better are the results. When it is remembered,
however, that the first successful suture of a per-
forated gastric ulcer was performed less tlian
fifty years ago, that the removal of a diseased

6 DIAGNOSIS OF THE ACUTE ABDOMEN

appendix has only been a practical surgical question
for about the same time» that opening the abdomen
for intestinal obstruction was regarded until com-
paratively recently as the last instead of the first
resort, it will be recognized that the modern mental
attitude tow’ard abdominal emergencies has only
been adopted within the lifetime of this generation.
But the old view’ that delay is permissible still
lingers in some quarters, for custom changes
slowly. There are still some w'Jio justify W'aiting
until a local abscess has formed in many cases of
appendicitis, some who advocate the trial of such
uncertain methods for reducing an intussusception
as injection of fluid or air per nnum, and there
are certainly many who treat cases of intestinal
obstruction by medical measures for several
days before sending them to the surgeon. Public
opinion on the subject needs education, and
such education must come from the practitioner.
The attitude of some patients who assert — and
act up to tlieir assertion — ^that tliey would rather
die without operation than obtain a good chance of
cure by undergoing some surgical procedure, is
surely the result of an, imperfect diffusion of the
knowledge that surgery offers the best chance of
life in such emergencies.

The recovery-rate from acute abdominal disease
increases in proportion to the cnrlincss of diagnosis
and treatment. That there is a considerable
amount of abdominal disease diagnosed rather
late is suggested by the following statistics
taken from the Kcgistrar-Gcneral’s Report for
England and ^Yalcs for 1937. In that year there
died :

THE PRINCIPLES OF DIAGNOSIS 7

From acute appendicitis . 2821
„ intestinal obstruction . 2560
,, hernia . . , 2103

Take the last-mentioned only. Though we are
furnished with no particulars, it is clear that most
of these hernice must have been obstructed or
strangulated. A strangulated hernia is that form
of intestinal obstruction which should be, and most
probably is, most readily diagnosed. Wliy, then,
the mortality ? Because it is not realized that
the dangers of prompt operative interference are
less than those of waiting and seeing if the ac-
companying obstruction will right itself under
treatment of a non-operative character. Fomenta-
tions and icebags are not so safe as a knife and
a few sutures. Taxis is in the witer’s view only
justifiable when dealing Avith an easily reducible
hernia.

If, in cases showing such an obvious cause for
intestinal obstruction as a strangulated hernia,
delay is permitted, we can the more readily under-
stand how the remaining statistics mentioned above
are produced. In early diagnosis lies the saving of
tliousands of lives.

3. The necessity of the principle of making a
thorough routine examination of every acute abdo-
minal case sYiouVd ruAnecd much emphasis, one
is to make a correct diagnosis a complete routine
examination should be the rule. Few omit to
feel the pulse and take the temperature — ^yet
many a serious abdominal crisis may show at the
time of examination a normal pulse and tempera-
ture., It is more important to insert the finger

8 DIAGNOSIS OF THE ACUTE ABDOMEN

into the lo^^er end than to put the thermometer
into the upper end of the alimentary tract Jlorc
early^ cases will be diagnosed by palpating the
pelvic peritoneum than by palpating the pulse.
Few would forget to ask whether the bowels ucre
constipated or not, but many might forget that it
IS quite as important to submit the urine to the
chemical question of boiling In the most per-
functory examination one is almost bound to lay
the hand on the patient’s abdomen, and if the
latter be tender and rigid, the assumption may be
made that the condition is a local peritonitis, though
a stethoscope applied to the loner part of the chest
might possibly reveal the fact that the origin of
the symptoms was a diaphragmatic plcurisj
The exact order or method of examination nlncli
one may follow is a matter of indn idunl choice or
preference, but the routine followed by the nriter is
indicated and described in the ■succeeding chapters
4. Many examinations of the abdomen ore impcr
feet because the practitioner docs not act upon the
important pnncipJc of applying his hnoivledge oj
anatomy It is ncll to cultuatc the habit of think-
ing anatomically m every case nhere the knonledge
of structural relations can be put to ad\antnge.
There arc ^ cry fen abdommnl cases in nliich tins
cannot be done Application of aiintomj makes
diagnosis more interesting and more rational The
of some fJoubtSui pomk tJje dj/fm'/jtjuo-
tion of the possible causes of a pain, the determina-
tion of the exact site of a diseased focus, often depend
upon small anatomical points One is actustomed
to mar\cl at the accurate diagnoses of the neurolo-
gist, nluch arc for the most part based upon a

THE PRINCIPLES OF DIAGNOSIS 9

sound knowledge of microscopic anatomy. Nothing
like the same accuracy is yet achieved in abdominal
diagnosis, but it is the writer’s faith that such will

Fio - — Deawmg to ehow Aostoaiical ports eoneernod la obturator
test. A ss ilio psoaa ; B •=> tnBamed appendu: ^nth small abscess •
£7 = obturator mtemns, B = lBTolor am, B = AlcocJt’s conoj;
F « rectum.

come in time by carefully applying the knoi\ ledge
of anatomy and physiology.

One can best illustrate the value of applied

10 DIAGNOSIS or THE ACUTE ABDOMEN

anatomy in abdominal diagnosis b> considering those
structures ivliich are least \ariable in tlieir position
— the voluntary muscles and the cerebro spinal
nerves The frontispiece shows well the position
of the different muscles, the diaphragm, the psoas,
the quadratus lumborum, the erector spina?, the
lateral abdominal muscles, the recti, the p}riformis
and the obturator internus Each of these muscles
may be of valuable clinical significance, for if any
of them be irritated directly or reflevly by inflamma-
tory changes it becomes tender and rigid, and pam
is caused when the muscle fibres are mo\ ed Ev cry-
one IS acquainted inth the rigidity of the rectus and
lateral abdominal muscles when tliere is a subjacent
inflammatory focus, but few take much note of the
rigidity of the diapliragm in a case of subplirciuc
abscess, because the diapliragm is miisiblc and
impalpable Its immobility may be deduced, how-
ever, by tlie impairment of movement of tlie upper
part of the abdominal wall, and if the X-rajs are
available the rigiditj and absence of movement of
the diaphragm can be directly demonstrated
It will be remembered that in some cases
of appendicitis and other conditions affecting the
psoas muscle there is flexion of the thigh, due
to contraction of the muscle consequent on direct
or reflex irritation, but how often does anyone test
the slighter degrees of such irritation bj causing
Ui.e ^xtieat to he on. the oy^iositc side and extending
to the full the tliigli on tlie affected side ’ Again, tlic
obturator mternus is covered bj a dense fascia and
IS not readily irritated by pelvic innanimation , but
if tliere be an abscess (e g one caused b} a ruptured
appendix) immediatclv adjacent to tlic fascia, pain

THE PRINCIPLES OF DIAGNOSIS 11

wiJI be caused if the muscle be put through its full
movement by rotating the flexed thigh inward to its

Flo. 3 — Diagram to show the sites on posterior surface of body to which
pain 13 referred in acute abdominal conditions.

extreme limit. The pain is referred to tlie hypo-
gastrium. This sign is not present in every case of

12 DIAGNOSIS OF THE ACUTE ABDOMEN

pelvic appendicitis, and may occur in other pelvic
conditions, such as pelvic Ii'ematocele, but ivlien
present it denotes a definite pathological change
(Fig 2 )

The application of the knoi\ledge of the anatomi-
cal course and distribution of the segmental ncr\cs
IS also important IMien a patient complains of
loin pain radiating to the corresponding testis one
remembers the embryological fact that the testis
is developed in the same region as the kidncj , and
though the former tra\ els to the scrotum just before
birth, yet in suffermg it shous its sympathy mth
and serves as an indicator for the intra abdominal
structure nluch nas de\eloped near it Of course,
pain referred to the testicle does not alwajs denote
primary genito urinary disease It is probable
that the mam nerve supply to tlic a ermiforin
appendix comes from the tenth dorsal segment,
so that pain in one or both testicles may be caused
by such a condition as appendicitis The dorsal
distribution of referred pain should also be noted
(See Fig 3 )

Another segmental pain of great importance is
that referred from the diaphragm The diapliragm
begins to develop m the region of the fourth ccr\ ical
segment from uhich is obtained the major part
of its muscle fibres Nerve fibres, mainly from the
fourth cerv ical nerv c, accompany the musclc-fihrcs
and constitute the phrenic nerve Tlie groirth of
the tlioracic contents causes the muscle to be dis-
placed caudal vs ards, and it finally takes up its
position at the loner outlet of the thorax llic
phrenic nerv es elongate to accommodate themseh cs
to the displaced muscle From the diagnostic

THE PRINCIPLES OF DIAGNOSIS 13

point of view the separation from the original
position is extremely valuable, for if in upper
abdominal or lower thoracic lesions pain be felt, or

Pjo i , — Diagram to indiCAto (1) th« shoulder area m which phrenic
irritation may came pain, (2) line of diapliragm.

hyperfestliesia be detected m the region of distribu-
tion of the fourth cervical nerve, it is a strong pre-
sumption that the diaphragm is irritated by some

14 DIAGNOSIS OF THE ACUTE ABDO’MEN

inflammatory or other lesion Hilton one of
the first to suggest that the shoulder pim might
be referred to the shoulder via the phrenic ner\c,
and Ferguson proved expenmentallj fiftj jears
ago that the phrenic nerve contained afferent as
well as efferent fibres Yet the significance in
abdominal diagnosis of constant or intermittent pain
in the region of distribution of the fourth cervical
nerves is still either not understood or scriouslj
neglected Pain on top of the shoulder maj be
the onlj signal which an inarticulate liver abscess
threatening to perforate tlic diaphragm, maj be able
to produce The agonizing pam of a perforated
gastric ulcer is felt on top of one or botli shoulders m
proportion as the acrid and irritating fluid impinges
against the diapiiragm and irritates tlie terminations
of the phrenic nerves on one or both sides Pam
may also be referred to tJie shoulder m cases of
subphremc abscess, diaphragmatic pleunsj, acute
pancreatitis, gall stones, ruptured spleen, and in
some cases of appendicitis witli peritonitis The
pam is felt either m the supraspinous fossa, over
the acromion or clavicle, or m the subclavicular
fossa (Fig 4 ) There is clinical evidence to
support the opinion that tliere is a correspondence
of nerve distribution over tlie diaphragm and over
the acromio clavicular region, so that lesions affect'
mg a certain portion of the diapiiragm cause pain
over the corresponding part of tlie shoulder area on
the same side of the body Pam on top of both
siioulders indicates a median diaphragmatic irrita
tion The shoulder pain is apt to be overlooked,
since the patient ma> tcrmit ‘rheumatism ’’{Fig 5 )
Errors m diagnosis also result from want of

THE PRINCIPLES OF DIAGNOSIS 15

appreciation of another anatomical point, i.e. the
lack of representation in the muscular abdominal
wall of the segments which form the pelvis, so that
irritation of the pelvic nerves (e.g. from pelvic
peritonitis) causes no abdominal-wall rigidity.

Fio 6 — Dmg^om to bIiow visceia m relation with dtapliiagm {Posterior
view mth back p&rt at diaphragm cut away } St stomach ,
Sp *= spleetu

Peritonitis commencing deep in the pelvis may
therefore be unaccompanied by any rigidity of the
hypogastric abdominal all.

The above illustrations serve to demonstrate the
importance of applying knowledge of anatomy in
abdominal diagnosis. It is unnecessary to cm-

IG DIAGNOSIS OF THE ACUTE ^VBDOMEN

phasize the great importance that a thorough
acquaintance with the normal size, position, and
relations of the abdominal viscera Ins in connexion
with the elucidation of abdominal disease

5. The localization of inflammatory lesions is
aided particularly by knoi\ ledge of anatomy,
whilst in obstructive lesions the application of
physiological knowledge plays perhaps a more im
portant part The question of shock, the nature
of the movements and sensations of the intestine,
not to mention the various and important physio
logical tests demonstrating visceral functional dc
rangements, are all intimately bound up \\ith
the problem of tlie acute abdomen Very im
portant also is tlie study of tlie effect of \ anous
toxins upon the \ iscera and tlic neuro muscular
reflexes of the abdomen

A \ery large number of urgent abdominal cases
are accompanied by pain due to abnormal condi-
tions in tubes whose walls are composed mainly of
unstriped muscle fibres Tliere is no high grade
sensibility in such tubes It is possible to crush,
cut, or tear intestine iiitliout the fully conscious
patient experiencing any pain, yet eicryonc is
aware that pain does take origin from the intestine
Wiat induces such pam ’ Hurst, in his lectures
gi\en some years ago, supplied tlic answer The
required stimulus is strctclung or distension of tlie
tcfbe of potn anstoff from a taho ^

involuntary muscle is therefore indicative of local
distension, either by gas or fluid In mild degrees
in tlic intestine this is commonly called flatulence,
m greater degrees m either intestinal, biliary, renal,
or uterine tubes it is callctl colic Severe colic

THE PRINCIPLES OP DIAGNOSIS 17

always indicates obstruction causing local disten-
sion or violent peristaltic contraction It occurs in
paroxysms, and the pain, which is often of an
excruciating nature, is referred to the sympathetic
centre from which the nerves come, and also to the
segmental distribution corresponding to the part
of the spinal cord from which the sympathetic
nerves to the affected viscus are derived Colic
of the small intestine causes pain referred chiefly
to the epigastric and umbilical regions, whilst large
intestine colic is usually referred to the hypogas-
trium The pain of biliary colic is usually felt
more in the right subscapular region, whilst that
of renal colic is felt m the lorn and radiates to the
corresponding testicle Severe colic is certainly one
of the most terrible trials to which a human being
can be subjected The excessive stimulation of
the nerve centres is often reflected into motor
channels so that the patients frequently fling
themselves about, twist and double themselves up
in a characteristic way If, therefore, a patient
gets paroxysms of pain which are accompanied
by the most violent restlessness of agony, the
chances are that the condition is some form of
obstruction and not peritonitis, for m the latter
condition movement generally increases the pain
The physiology of shock is still a subject of dis
cussion, and rather widely differing opinions are
held thereon But wliatever views be held as to
the exact metabolic or nervous changes winch are
responsible for the symptoms, we believe that feu
would fail to allow that in acute abdominal disease
two varieties can be recognized One is the initial
or primary siiock due to sudden stimulation of
2

18 DUGNOSIS OP THE ACUTE ABDOMEN

many nerve-terminals, as in the perforation of a
gastric ulcer into tlie general peritoneal cavity, or
the severe stimulation of a few, as for example in
biliary colic.

The second variety of shocTc, which might be
termed late, toxic, or secondary shock, is that in
which somewhat similar symptoms arise at a later
stage, partly no doubt from severe afferent nerve
stimulation, but chiefly from the absorption of
poisons which directly affect the higlier nerve
centres. The terminal stage of this secondary
shock is commonly termed collapse.

Between primary and secondary shock, as here
described, there is often an interval, a latent period,
during which the observer may easily be deceived.
In many cases of perforated ulcer the sudden
stimulation of the nerve-endings in the peritoneum
or subperitoneal tissue causes severe shock. After
a time the nerve-equilibrium is restored and tlie
pulse, respiration, temperature, and appearance of
the patient improve so much that one might think
the pathological process was stayed or improving.
Soon, however, the symptoms of peritonitis dominate
the scene, and one realizes that the calm period
was but that of physiological reaction. Tliis period
is the cause of many mistakes in diagnosis.

Another physiological fact of importance is
that hypersEStliesia and tenderness due to irrita-
tion of nerves by a unilateral lesion are not usually
felt on the opposite side of the body. For ex-
ample, a right-sided pleurisy will sometimes cause
tenderness and rigidity in the right, but not in
the left iliac region. If the fingers pressed
well into the left iliac fossa and pushed deeply

THE PRINCIPLES OF DIAGNOSIS 19

towards the right side across the middle line evoke
tenderness, it will indicate a deep inflammatory
lesion in the right iliac region.

6. In diagnosing acute abdominal disease it is
always necessary to exclude medical diseases before
concluding that the condition is one needing surgical
intervention. Certain aspects of disease which
may simulate the acute abdomen can only be learnt
either in the medical wards of a large hospital or
in an extensive general medical practice. Typhoid
fever, cardiac derangements, chronic interstitial
nephritis and arterio-sclerosis, cirrhosis of the liver,
tuberculous peritonitis — all these and many other
medical diseases will sooner or later cause doubt in
abdominal diagnosis. Tiie one who would be
prepared thoroughly to examine and correctly to
diagnose the acute abdomen must at any rate know
how to use, even if he be not expert in the use of,
the ophthalmoscope, the sphygmo-manometer, the
leucocytometer, and the stethoscope— not to men-
tion the urine-testing apparatus.

Opening of the abdomen is not to be advised with
too light a heart. The dextrous hand must not be
allowed to reach before the imperfect judgment.
Abdominal section is only to be made on the recom-
mendation of a mature judgment after a thorough
examination. It is regrettable to have to say after-
wards that one did not know that there was severe
albuminuria, or that the patient was the subject of
tabes dorsalis, or that the lungs were not examined.
Perhaps the traditional precedence of the physician
over the surgeon is not without its significance
even to-day.

If, however, after careful examination one comes

20 DIAGNOSIS OF THE ACUTE ABDOMEN

to the conclusion that there is within the abdomen
the early stage of a pathological process whicli
tends to get worse and which is amenable to surgical
treatment, there should be no Iiesitation in recom-
mending operation, even though the patient and
liis relatives may not think the condition serious.
Correct diagnosis is the basis of firm counsel.

CHAPTER II

METHOD OF DIAGNOSIS : (I) THE HISTORY

In diagnosing acute abdominal disease it is well to
have a routine method of examination, not to be
slavishly followed, but to be modified according to
circumstances. Increasing experience enables one
to dispense with some parts of the examination — for
example, a woman collapsed and blanched with
obvious intra-abdominal hiemorrhagc is not to be
subjected to an examination which entails a risk of
producing further hasmorrliage — but in general, and
when urgency permits, routine method is desirable.

The accompanying scheme, to be filled in during
the examination of the patient, has been used by
me at St. Mary’s Hospital for some years, and may
be found useful as a general guide. There are two
main sections in this scheme : one devoted to the
ascertaining of the history of the condition for
which advice is sought ; the other reserved for the
result of the physical examination of the patient.
The former includes both the'story of the present
illness and any more remote disease which may
possibly bear upon the present derangement.

History of present condition. — It can be con-
fidently asserted that a large number of acute ab-
dominal conditions could be diagnosed by consider-
ing carefully the history of onset. That is only
possible, however, when each symptom is carefully

FORM FOR ACUTE ABDOMINAL CASES

P,3Uent a Name Sex Age

Addws

Date and lime of examination

HISTORY OF PRESENT CONDITION

Exact Tmr or Onset Mode or Onset — Acute or GraduaL

Pain — (a) Situation at first [b) Has it shifted T

(c) Character (d) Any radiation ?

(<) Pam on nuctuiilioiv.^

VouiTivo — Before — at same time — or aome hours after pain

Hoir often * Cl araeter of vomit

Nausea

Bowels — Regular usually ♦

Diarrhcca ?

MosTnoATiov •'-Exact date of last period
RTiether last period + or —

■RTien last open.

Aoy blood us motions T

Famful or sot

PAST HISTORY
Aoy ser ous previous illness *

Indiocstion »If so, how long after meals before pain comes
Jaundice Metsna Hiematemesis

Ilsmaturia. Loss of weight

CovriNEUENTS (if any)

^ PRESENT CONDITION

Pulse. Blood rREssuBs Resr Teup

General ArrEASANCE

Abdoucn — Faub Tenderness Cutaneous 11 gidily Dulensloo
Hyperaistheaia

Slovemcnt on respiration.

Free fluid
Thigh rotation test
Rectal Examination
Chest Examination

Spine KkeeJerer

Urine.— Blood Pus

Vacinal DlSCnAROE.

Bqiancal Examination

Tumour or external
hernia.

Liver dutlnevs

rcriu

Sugar

X»BAr Examination

22

THE HISTORY

23

appraised in relation to the other symptoms, so
that its significance is properly understood We
shall therefore consider each item m the case-form
separately

Age. — To know a patient’s age is helpful, since
the incidence of certain conditions is limited within
certain years Acute intussusception occurs gener-
ally in infants under two years of age , appendicitis
seldom occurs in infancy, but is most common in
young adolescents Obstruction of the large in-
testine by a cancerous strictiye is seldom seen before
tliirty, is infrequent before forty, but is the com-
monest cause of intestinal obstruction in persons
over forty years of age Acute pancreatitis is
seldom or never seen m those under middle age. A
perforated gastric ulcer is a great rarity in anyone
under fifteen years Conditions such as cholecystitis
or a twisted pedicle of an ovarian cyst may occur
in childhood, though much more common in adult
life All the acute conditions which are due to
derangements of the de\elopmg ovum or its sur-
roundings are naturally only found in women
between the limits of the child-bearing period

Exact time and mode of onset.— It is'frequently
possible for the patient to fix the exact time at
which the pain started The awakening out of
sleep by acute abdominal pain is so startling that
it IS not forgotten Acute appendicitis very com-
monly, and perforation of a gastric ulcer not in-
frequently, commence this manner. It is no
ordinary pain whicli begins thus

Many acute conditions appear to be precipitated
by some slight exertion or by the internal distur-
bance caused by the energetic working of an

24 DIAGNOSIS OF THE ACUTE ABDOMEN

aperient. Many cases of incipient appendicitis
become much worse soon after the administration
of castor oil or its equivalent. The temporary’
increase of intra-abdominal tension caused by any
slight straining effort may cause the giving way of
the thin floor of a gastric ulcer, or the rupture of a
pregnant Fallopian tube.

It is also important to determine whether the
condition began injmediately after some injury ;
apparently trivial abdominal injuries may be
accompanied or followed by serious lesions.

Tlie acuteness of onset giv'es some indication of the
seventy of the lesion. Ask if the patient fainted or
fell down collapsed at the onset of sjTnptoms. Per-
foration of a gastric or duodenal ulcer and acute pan-
creatitis are the only two abdominal conditions likely
to cause a man to faint. In a woman the rupture
of an ectopic gestation usually causes fainting.

JIany cases of intestinal obstruction are gradual
in onset, culminating in an acute crisis. Strangula-
tion of the gut, however, is accompanied by very
acute symptoms from the first. The symptoms
due to torsion of the pedicle of an ovarian cyst arc
also usually acute from the start.

To know the exact time of onset is useful in
estimating the probable pathological changes that
Iiave ensued ; for example, it is not usual for an
appendix to perforate witliin twenty-four hours of
the onset of symptoms, so, unless the symptoms
definitely point to diffuse peritonitis, one may gi\e
a better prognosis for the operation of appendi-
cectomy if performed within that time. Again, it is
only by ascertaining the precise moment of onset
that one can tell whctJier the apparent ncll-hcing

THE HISTORY

25

of the patient corresponds to the stage of reaction
which IS seen in some conditions — notably in
patients ^\lth perforated gastric or duodenal ulcer
Fam. — The greatest importance attaches to the
very careful consideration of the onset, distribution,
and character of the pain

Situation o£ the pain at first. — When the peritoneal
cavity IS flooded suddenly by either blood (from a
ruptured tubal gestation sac), or pus (e g from a
ruptured pyosalpinx), or acrid fluid (from a per-
forated gastric ulcer), the pam is frequently said
to be felt “ all o\ er tlic abdomen ” from the first.
But the maximum intensity of pain at the onset is
likely to be m the upper abdomen m the last-
mentioned and m the louer abdomen m the two
former conditions In perforated duodenal ulcer
the pain may be at first more acute m the right
hypochondnum and right lumbar and iliac regions,
owing to the irritating fluid passing down chiefly
on the right side of the abdomen
Pam arising from the small intestine, whether due
to simple colic, organic obstruction or strangulation,
IS always felt first and chiefly m the epigastric and
umbilical areas of the abdomen, i e in the zone of
distribution of the ninth to eleventh thoracic nerves
which supply small intestine \na the common mesen-
tery Remembering that the .appendicular nerves are
deri\cd from the same source as those ■which supply
the small intestine, it is not surprising that the
pam at the onset of an attack of appendicitis is
usually felt m the epigastrium "V^licn small intestine
IS adherent to the abdominal wall, pain caused by
its peristaltic mo\emeiit is referred to that part of
the abdominal wall to which the gut is adherent

24 DIAGNOSIS OF THE ACUTE ABDOMEN

apenent Many cases of incipient appendicitis
become much norse soon after the administration
of castor oil or its equivalent The temporary
increase of intra abdominal tension caused b> an}
slight straining effort may cause the giving ivay of
the thin floor of a gastric ulcer, or the rupture of a
pregnant Fallopian tube

It IS also important to determine nhetlier the
condition began immediately after some injury ,
apparently trivial abdominal injuries may be
accompanied or folloued by serious lesions

The acuteness of onset gives some indication of the
se\ enty of the lesion Ask if the patient fainted or
fell dowm collapsed at the onset of symptoms Per
foration of a gastric or duodenal ulcer and acute pan*
creatitis are the only tn o abdominal conditions likcl}
to cause a man to faint In a woman the rupture
of an ectopic gestation usually causes fainting
Many cases of intestinal obstruction arc gradual
in onset, culminating m an acute crisis Strangula-
tion of the gut, however, is accompanied b} i erv
acute symptoms from the first The sjmptonis
due to torsion of the pedicle of an o\anan C}st arc
also usually acute from the start
To know the exact time of onset is useful in
estimating the probable patiiological cimnges that
have ensued, for example, it is not usual for an
appendix to perforate withm tnent} four hours of
the onset of symptoms, so, unless the symptoms
definitely point to diffuse peritonitis, one may give
a better prognosis for the operation of nppendi*
cectomy if performed within that time Again, it is
only by ascertaining the precise moment of onset
that one can tell whether the apparent well being

THE HISTORY

25

of the patient corresponds to the stage of reaction
which IS seen in some conditions — notably in
patients with perforated gastric or duodenal ulcer.

Fain. — The greatest importance attaches to the
very careful consideration of the onset, distribution,
and character of the pam

Situation of the pain at first. — When the peritoneal
cavity IS flooded suddenly by either blood (from a
ruptured tubal gestation-sac), or pus (e g from a
ruptured pyosalpinx), or acrid fluid (from a per-
forated gastric ulcer), the pain is frequently said
to be felt “ all o\ er the abdomen ” from the first.
But the maximum intensity of pain at the onset is
likely to be in the upper abdomen m the last-
mentioned and in the lower abdomen in the two
former conditions In perforated duodenal ulcer
the pain may be at first more acute in the right
hypochondnum and right lumbar and iliac regions,
owing to tlie irritating fluid passing down chiefly
on the right side of the abdomen
Pain arising from the small intestine, ^^hether due
to simple colic, organic obstruction or strangulation,
IS always felt first and chiefly in the epigastric and
umbilical areas of the abdomen, i e in the zone of
distribution of the ninth to eleventh thoracic nerves
IV Inch supply small intestine via the common mesen-
terj Remembering that tlie appendicular nerves arc
derived from the same source as those which supply
the small intestine, it is not surprising that the
pam at the onset of an attack of appendicitis is
usuallj felt in the epigastrium Allien small intestine
is adherent to the abdominal wall, pam caused by
its peiistaltic movement is referred to that part of
the abdominal wall to which the gut is adherent

26 DIAGNOSIS OF THE ACUTE ABDOMEN

The pam of large gut affections is more commonly
felt at first in the hypogastnum, or, in the case of
the ciecum and ascending and descending colon,
when the meso caicum or meso colon is very sliort
or anting, at the actual site of the lesion
The shifting or localization of the pam is often
significant. After a blow on the upper part of tlie
abdomen, if local pam at the site of injury' be the
first complaint, but m a few liours the pam be re-
ferred more to the hypogastnum, one must suspect
rupture of intestine and consequent gravitation
of the escaping fluid to the peliis Similarly,
localization of pam m the right ihac fossa some
hours after acute epigastric pam is usually due to
appendicitis — ^though occasionallj the same se-
quence IS see^ with a perforated piloiic or duodenal
ulcer, or m a case of acute pancreatitis

The character of the pam is occasionally a lielp as
to the nature or seriousness of the condition. Tlie
general burning pain of a perforated gastric ulcer,
the agony of an acute pancreatitis, the sharp con*
stnetmg pam which takes awaj the breath in an
attack of biliary colic, and tlic griping pam in
many cases of intestinal obstruction contrast with
the acute aching of many cases of appendicitis
with abscess, or the constant dull fi\ed pain of a
pj onephrosis

Radiation of the pain is frequently diagnostic.
This is speciallj true of the colics m which pain
radiates to the area of distribution of the nencs
coming from that segment of the spinal cord which
supplies tlie affected part Thus in bilmrj colic the
pam is ii ^ ’•red to the region just under

the inferior ’ scapula (cightli dorsal

THE HISTORY

27

segment), whilst renal colic is frequently felt m the
testicle of the same side

In many conditions of the upper abdomen and
lower thorax pam is referred to the top of the
shoulder on the same side of the lesion (see Chapter
I), and special inquiry should always be made as
to pain or tenderness over the supra spinous fossa,
the acromion, or the clavicle

It IS always well to ascertain tf the pain is in
fitienced by respiration Pleuritic pain is usually
orse on taking a deep inspiration , and is diminished
or stopped during a respiratory pause Biliary colic
may cause inhibition of movement of the diaphragm,
and the pam may be increased by a forced respira-
tion In many cases of peritonitis, mtra peritoneal
abscess, or abdominal distension due to intestinal
obstruction, pain will be caused on inspiration
Special varieties of pam — It is necessary to ask
if there be any pain during the act of micturition,
for the presence or absence of such pain is frequently
of great significance In addition to its causation
by primarily urinary, conditions, e g pyelitis, stone
in the kidney or ureter, or acute hydronephrosis,
pain on mictuiition is not infrequently caused by a
pelvic abscess uhich lies close to the bladder, or
by an inflamed appendix which irritates the right
ureter Pain in the testicles is to be expected in
renal colic, but it is also found occasionally in acute
appendicitis

Vomiting — In acute abdominal lesions, apart
from acute gastritis, vomiting is almost always due
to one or more of three causes

(1) Severe imtation of the nerves of the pen-
toneum or mesentery^ e g consequent on the

28 DIAGNOSIS OF THE ACUTE ABDO.MEN

perforation of a gastnc ulcer or of a gangren-
ous appendix, or torsion of an ovarian cjst
pedicle

(2) Obstruction of an involuntary muscular
tube, vvhetlier it be the biliary duct, the ureter,
the uterine canal, or the intestine

(3) The action of absorbed tovms upon the
medullary centres

(1) It needs little imagination to picture the
intensity of stimulation of tlie nerve endings in tlie
peritoneum by the acid gastric }uice flowing frcclj
into the peritoneal cavity, nor is it surprising that
a patient should vomit very soon after the onset of
such irritation. But tlie rapid and copious pouring
out of diluting fluid from the irritated peritoneal
surface soon dilutes the acid gastric juice and lessens
the irritation, so that vomiting is seldom persistent
after the perforation of a gastric ulcer.

In acute pancreatitis the ccehac plc\us is so
intimately associated with tlie inflamed organ that
the reflex stimulus is very great and vomiting is
therefore very severe. It is frequently persistent,
since there is no mitigation of the sev ere stimulus
apart from operation or gangrene of the organ

Strangulation of a coil of intestine and torsion
of the pedicle of an ovarian cjst arc examples of
sudden catastrophes in winch sudden and severe
sUtuulQjtuin. of many sympathetic nerves causes
vomiting to occur early and to be persistent.

(2) Stretching of involuntary muscles causes
pain, and if the stretching be extreme, vomiting
occurs. Obstruction of anj of the muscular
tubes causes peristaltic contraction and consequent

THE HISTORY

29

stretching of the muscle-wall due to distension, and
vomiting is tlierefore common with sucli obstruc-
tion. This is well seen in all the colics, biliary,
renal, intestinal, and uterine. Behind the obstruc-
tion the tube becomes somewhat dilated, and, as
each peristaltic wave passes along, the tension and
stretching of the muscular fibres are temporarily
increased, so that the pain of colic comes usually in
spasms. Vomiting usually occurs at the height of
the pain.

In intestinal obstruction there is the additional
factor that the contents of the intestine are
mechanically prevented from progressing omvard,
and a reversed current is set up, probably as the
result of antiperistalsis. The contents of the in-
testine, sometimes as far down as the site of obstruc-
tion, are therefore vomited.

(8) Toxic vomiting is seen in cases of septic
peritonitis. It is possible that in intestinal ob-
struction the vomiting is partially due to tlie effect
of absorbed poisons upon the medullary centres.

The relationship of pain to vomiting .- — It is im-
portant always to inquire tlie exact time of vomit-
ing relative to the onset of pain. In sudden and
severe stimulation of the peritoneum or mesentery
vomiting is early, coming on soon after the pain.
In acute obstruction of the ureter by a stone or of
the bile-duct by a calculus vomiting is early, sudden,
and violent. In intestinal obstruction the length
of interval before vomiting ensues gives some indi-
cation as to how high in the gut the obstruction is
situated. If the duodenum has become obstructed
by a gall-stone, vomiting comes on almost as soon
as the pain, and is for a time, and until the stone

30 DIAGNOSIS OF THE ACUTE ABDOMEN

passes on, frequent and \iolent If the lower
end of the ileum be constricted (apart from
strangulation, which leads to earlj vomiting), the
vomiting may not occur for four or more hours
according to the acuteness of the stoppage In
large bowel obstruction the vomiting is usuallj
quite a late feature, though nausea is often present
at a much earlier stage

In appendicitis pain almost always precedes the
vomiting, usually by three or four hours, sometimes
by twelve or twenty four hours or ei en longer
Rarely indeed does the vomiting occur simul-
taneously ivith the onset of pam, and very rarely
does the pam start after the \omiting

The frequency of ike vomiting usually \arics
directly as the acuteness of the condition Frequent
vomiting at the onset of an attack of acute
appendicitis usually means that the appcndiv is
distended on the distal side of a stricture or con-
cretion, and signals the immediate danger of
perforation Frequent vomiting later in the course
of an appendicitis usually means extension of
peritomtis

There are, however, many serious abdominal
conditions in which vomiting is either infrequent,
slight, or absent Internal h'emorrhage from a
ruptured ectopic gestation is often accompanied by
little or no ^ omiting After the initial shock due
to perforation of a gastric or duodenal ulcer tlicre
is often a latent period before symptoms of peri-
tonitis assert tlicmsehcs During tins period
vomiting may not occur and nausea may not be
complained of

In obstruction of the large intestine \omitnig is

THE HISTORY

31

a late or infrequent symptom This is very notice-
able in cases of intussusception, wliere the absence
of vomiting may deceive as to the acuteness and
danger of the condition When vomiting occurs in
undoubted obstruction of the large intestine it is
generally due to the failure of the ileo caecal valve
allov mg the back-pressure to distend the lower
ileum

In obstruction high up m the small intestine
vomiting is frequent and copious m quantity

The character of the vomit needs to be noted
In acute gastritis, which in severe cases may give
rise to alarming abdominal symptoms, the vomit
consists of the contents of the stomach possiblj
mixed with a little bile In the colics the vomit is
commonly bilious In cases of sei ere sympathetic
shock, such as occurs with acute torsion of a viscus,
it IS common for tlic patient to retch frequently
but vomit very little

In intestinal obstruction the character of the
vomited material vanes First the gastric con-
tents, then bilious material, tlien greenish yellow,
yellow, and finally brown freculent smelling fluid is
ejected Fasculent vomit is pathognomonic of
obstruction of the intestine — either mechanical or
paralytic

Nausea and loss of appetite are induced m many
people who do not vomit In some patients it
appears to need a greater stimulus to produce
vomiting than m others In the same person
different grades of the same kind of stimulus may
produce anorexia, nausea, or vomiting Therefore
it is always important to inquire foi the tivo former
as well as the latter Acute loss of appetite is

32 DL4GN0SIS OF THE ACUTE ABDOJIEN

always significant. In a child especially a sudden
distaste for food accompanied by abdominal pain
should always cause one to make a very careful
examination for appendicitis. In questioning a
child it is well to find out the last meal that the
child really enjoyed, and the first for which it had
no eagerness.

Bowels. — It is, of course, important to investigate
the condition of the bowels, but it is unwise to
attach too much importance to the simple fact of
constipation, unless accompanied by other symp-
toms. Wiat is of greater importance is any signifi-
cant departure from previously normal action of
the bowel. In a person who is accustomed to a
regular action of the bowels every day, the occur-
rence of constipation for several days may be of
serious import, especially if accompanied by
abdominal pain or flatulence.

The passage of several small loose motions
amounting almost to diarrheea is common at tlje
onset of many cases of appendicitis in children.
When hijpogosiric pain and diarrheea arc foUoiced
hy hypogastric tenderness and constipation suspect
a pelvic abscess. Tenesmus is sometimes a com-
plaint in cases of pelvic abscess.

The presence of obvious blood or slime in the
motions is to be asked after and looked for. The
significance of blood and mucus in the diagnosis of
intussusception is well known.

Menstruatioii. — Since pregnancy and the derange-
ments thereof play so large a part in the health
and disease of women, it is essential to inquire
into the regularity of menstruation. It is not
sufiicient to ask if the periods arc regular, the

THE HISTORY 38

exact date of the last penod must be ascertained
and any irregularity noted. Antedating or post-
dating of the normal period by a few days, or a
longer or more profuse loss or the reverse, must be
noted. Many patients with tubal gestation take
the uterine loss which occurs at the time of threaten-
ing tubal abortion or rupture as the normal men-
strual loss, if the haemorrhage happens to coincide
with the time of the usual monthly period In such
cases, however, it is nearly always possible by
careful questioning to ascertain that the loss is in
some way abnormal

Pain accompanying tlie period of a woman who is
not usually subject to dysmenorrhcea should make
one think of threatening early abortion, tubal gesta-
tion, or some condition unassociatcd with preg-
nancy.

Past history. — It is well to inquire concerning
any previous illness, e g typhoid fever, peritonitis,
appendicitis, or pneumonia, which may possibly
have a bearing on the present illness

Since many if not most abdominal pains are
loosely termed indigestion, inquiry should be
directed as to the occurrence of any pam which has
any relationship to the taking of food. Pam which
comes on two or two and a half hours after food
would suggest duodenal ulcer. Constant epigastric
pam made worse by the taking of food would make
one suspicious of carcinoma or chronic ulcer of the
stomach. Epigastric or right hypochondriac pain
iiregularly related to meals is in keeping with the
presence of gall stones.

Pievious attacks of jaundice, meliena, lucma-
temesis, and hccmatuna must briefly be inquired

34 DIAGNOSIS OF THE ACUTE ABDOJIEN

after, and it is well to find out if any great and
kno'\\ n loss of weight has occurred.

Previous residence in tropical climes and any
dysenteric history should be ascertained.

In a woman previous confinements or pregnancies
should be noted.

CHAPTER III

METHOD OF DIAGNOSIS : (H) THE EXAIVIINA-
TION OF THE PATIENT

The general appearance. — -The facial expression of
the patient will on occasion furnish valuable evi-
dence of the serious nature of the pain of which he
complains. The pale or livid face mth sweating
brow of a patient suffering from the initial shock of
a perforated gastric ulcer, acute pancreatitis, or
acute strangulation of gut is sufficiently distinctive,
whilst the deathly pallor and gasping respiration of
n woman with internal htemorrhage from rupture
of a tubal gestation leave little doubt as to the
diagnosis. But appearances are often deceptive,
and in connexion with acute abdominal disease it is
impoitant ever to keep in mind the reaction from
initial shock which commonly occurs and renders
latent even the most serious internal conditions.
Most surgeons of experience have seen patients
suffering from perforation of a gastric ulcer who
gave no indication from complexion or facial ex-
pression of the serious intra-abdominal condition
from which they were suffering. The so-called
abdominal facies is not infrequently absent in an
abdominal case. In the majority of cases of early
appendicitis the facial appearance of the patient
does not help at all. But in the late stages of all
varieties of acute abdominal disease the face tells
the observer much that he ought to know, but is

35

36 DIAGNOSIS OF THE ACUTE ABDOJIEN

sorry to learn The dull gaze of tlie eyes and the
ashen countenance of one suffering from se\cre
toxasmia, or the sunken cheeks and hoIIoi\ e}ed
aspect of the patient T\ho has been vomiting re
peatedly from internal obstruction or advanced
peritonitis can always be recognized by the skilled
clinician

The back of the observer’s hand placed on the
patient’s nose and cheek a\i 11 often determine
whether shock is present or collapse impending,
for a cold nose and cheek, due to failing capillarj
circulation, are usually mdicatue of one or the
other

If the aliE nasi are obser\ed to be moving the
attention should always be particularly directed to
the thorax, for a iiigh temperature witli moving
alai nasi generally means pneumonia It must be
remembered, however, that any abdominal con*
dition which in any way impedes the movement of
the diaphragm may be accompanied by movement
of the alas

The attitude id bed is noteworthy. The restless-
ness of those suffering from severe colic or from
mtra peritoneal hicmorrhage contrasts witli tlie
immobility and dislike of movement evinced by the
majority of those suffering from peritonitis Ask
a patient suffering from a perforated gastric ulcer
to turn on to his side, and one sees at once the
difficulty, circumspection, and pain wnth which the
movement is accomplished With extensive peri-
tonitis the knees are frequently drawn up to relax
the abdominal tension, vvliilst any inflammatorv'
condition in contact with the psoas muscle causes a
flexion of the correspondmg thigh

EXMIINATION OF THE PATIENT 37

In the early stages of many pathological states
of the abdomen, however, no great help is obtain-
able from observing the attitude

The pulse is too optimistic a friend to be relied
upon for guidance, either in diagnosis or prognosis,
in the early stages of acute abdominal disease.
Exception must be made of the weak rapid pulse of
the initial shock stage of many of the abdominal
catastrophes, but one can prove the unreliability
of the pulse as a general guide by stating what
every operator of experience knows, i e. that the
pulse may be regular m force and normal m fre-
quency, even though there be an acutely inflamed
appendix, or a ruptured intestine, or an obstructed
coil of gut, or even (rarely) an acutely inflamed
pancreas causing the abdominal pain A normal
pulse does not necessarily indicate a normal con-
dition of the abdomen

On the other hand, an increase in frequency of the
pulse IS a constant accompaniment of the more
advanced stages of peritonitis and hiemorrhage,
and after abdominal injury the careful observance
of the pulse hour bj iiour is of great value in estimat-
ing the nature or seriousness of the mtra-abdominal
trouble. In advancing peritonitis, also, there is
frequently a slight irregularity m force and an
occasional mtermittence of the pulse nhich may
be significant.

The pulse of late peritonitis — small, hard, rapid
so as to be almost uncountable — is usually a ter-
minal event, and is always of bad prognostic signifi-
cance.

If acute abdominal disease is to be diagnosed m
the early stages, it must first be realized by the

38 DIAGNOSIS OF THE ACUTE ABDOMEN

practitioner, who will see the case at the begin-
ning, that many, if not most, patients n ith serious
acute lesions of the abdomen have a normal
pulse for a considerable time during the early
stage.

The respiration-rate is chiefly of importance in
differentiating bebveen an abdominal and a thoracic
condition If the respiration-rate be raised to
double the normal at the inception of the illness,
the causative lesion is probably thoracic in origin
In general peritonitis, liowever, or in cases of
intestinal obstruction with great distension, or in
severe mtra-abdommal hiemorrhage, tlie breathing
may be much more hurried than usual, and with
some persons nervousness produces shallow and
more rapid respiration TJie pulse respiration ratio
IS of greater value in diagnosis.

Temperature. — ^A sub-normal, normal, or raised
temperature may accompany acute abdominal
disease. All three may be recorded in the same
case at different times In any severe abdominal
shock or in severe toxaemia the thermometer fre-
quently registers as low as 95® F or 96® F. This
IS the temperature, for example, often recorded at
the onset of an attack caused by acute pancreatitis,
acute intestinal strangulation, perforated gastric
ulcer, or severe intra peritoneal haimorrhage

At tlie onset of an attack of acute appendicitis
the temperature is usually normal, but within a few
hours it generally rises steadily to about 100 ® F.
or 101® F. When perforation occurs the tempera-
ture usually goes a little higher, but sometimes the
absorption of depressing toxins may bring down
the temperature to normal, or c\ en sub normal.

EXAINIINATION OF THE PATIENT 39

A normal temperature is often seen in the re-
action stage of a perforated gastric ulcer

The reaction stage of a ruptured ectopic gestation
IS usually accompanied by irregular but not high
fever

In intestinal obstruction the temperature is, as
a rule, normal or sub normal If any patient witli
abdominal pain is found to have a temperature of
104° or 105° at the onset of the illness, the thorax
or the kidney is very likely the seat of the disease
High fever is quite unusual during the early stages
of acute abdominal disease

Tongue. — Though usual it is by no means invari-
able to find the tongue furred m acute abdominal
conditions In acute appendicitis and acute in
testinal obstruction there is usually a slight coat on
the tongue and the breath is frequently foul.

The appearance of the tongue is a valuable guide
m cases of urjcmia, which may simulate intestinal
obstruction In renal failure the tongue is \cry
dry, and heavily covered wuth a brownish fur,
whilst there is a tendency for sordes to collect on
the teeth

ABDOQUNATi EXAQIIKATION
Before examining the abdomen it is well to learn
from the patient the exact place where the pain
started, and if there has been any alteration in its
location The exact point of maximal pam should
also be pointed out at the time of examination
Inspection of the abdomen will reveal at a glance
any abnormal local or general distension, and will
in some cases determine the presence of a tumour or
abdominal spelling All ihe fiermal orifices must

40 DIAGNOSIS OF THE ACUTE ABDOMEN

he inspected as a routine, and special attention
directed to the femoral canal, where, in a fat subject,
a small hernia is not difficult to overlook.

The respiratory-movement of the abdominal wall
is carefully to be noted, for any limitation indicates
some rigidity of the diaphragm or abdominal
muscles, or possibly undue distension. In the case
of a perforated ulcer which has ruptured into the
general peritoneal cavity, the abdominal wall hardly
moves in any part on respiration, whilst in appen-
dicitis the hypogastric zone, especially the right iliac
area, will very frequently be seen immobile. In
acute pancreatitis the epigastric zone is motionless,
and sometimes also the lower part of the abdominal
wall. With biliary colic there is sometimes inhibi-
tion of the diaphragm so that the respiratory move-
ment of the epigastric area of the abdominal wall
is diminished.

In performing palpation of tlie abdomen it is
hardly necessary to remind the reader tliat the hands
should be warm, that the examination sliould be
commenced by the hand at that part of the abdomen
farthest removed from the point of maximum
tenderness, and that gentle pressure should be made
by the soft pulp of the fingers. Palpation deter-
mines the extent and intensity of the muscular
defence or rigidity, locates any tender areas or
hypersEsthetic patches, and determines the presence
of any swelling. It is Avell to have the patient’s
thighs flexed while palpating the abdomen.

Muscular rigidity is a relative term. The con-
traction of the muscles may be firm, continuous, and
“ like a board,” as in many cases of general peri-
tonitis due to perforated ulcer, or the muscular

EXAMINATION OF THE PATIENT 41

fibres may not contract to any detectable extent
till the fingers are gently pressed on the abdominal
wall, when the muscles spring to attention to
defend the subjacent inflamed parts. There is also
an important mental factor in the production of
abdominal-wall rigidity. In some sensitive chil-
dren, and in some very apprehensive adolescents
and adults, the abdominal wall is held very rigid
even though there be very slight intra-abdominal
cause for it.

In pelvic inflammatory lesions rigidity is often
absent. In intestinal obstruction the muscles are
not usually held rigid. In rigidity due to thoracic
disease, if the muscle contraction be overcome by
continuous pressure the abdominal pain is not
usually increased, but if there be a subjacent in-
flamed area in the abdomen the pain becomes
greater as tlie hand presses in and overcomes the
muscular resistance.

It is exceedingly important to remember that
muscular rigidity and resistance are often very slight
even though there may be serious peritonitis ;
(1) when the abdominal wall is very fat and flabby,
and the muscles thin and weak ; (2) when the
patient is suffering from severe toxromia, and the
reflexes are dulled and diminished as the result of
the absorbed toxins. It is noteworthy that the
recti are usuailj'' more definitely rigid than the
lateral abdominal muscles.

Hypercesthesia. — Hypericsthesia may be tested
by pin-stroke or by light pinch. For routine use
the testing by lightly stroking with the point of a
pin is the best method to adopt. Care is taken
to hold the pin at an acute angle to the skin so that

42 DIAGNOSIS OF THE ACUTE ABDOAIEN

it does not scratch The abdominal skin is then
stroked from above downwards in several vertical
lines, first on the right side, then on the left The
patient is told to say at once if the pin stroke feels
sharper at any place It is ^v^se also to test the
lorn and posterior lumbar region in the same y\a\
Hypercesthesia may be detected {a) m tlie segmental
distribution of that part of the spinal cord from
which the affected viscus is inner\ ated , (6) along
the distribution of those peripheral nerves some of
whose terminals are irritated by the inflammatory
process It will be found that cutaneous hyper
sesthesia is present in half the number of acute
abdominal conditions nhich present themselves for
diagnosis Hyperesthesia nearly alvajs indicates
visceral or parietal peritoneal inflammation It is not
common to obtain hj'pcrresthesia m the upper abdo-
men Most commonly the hypersensitive area lies
below the umbilicus and vanes from an iliac triangle
on one or both sides to a small patch somewhere
within the limits of the triangle Occasionally a
complete band stretches right back to the spine
Though appendicitis is by far tlie most common
abdominal disease which gives rise to hypcra:sthesia
m the lower part of the abdominal viall, yet chole-
cystitis, perforated duodenal ulcer, pyelitis, cystitis,
and various kinds of peritonitis may also cause
cutaneous hyperscnsitivcncss in the area above
Poupart’s ligament It is, however, comparatively
rare to find an ihac triangle of hypcr'cstliesia in any
condition other than appendicitis IlypcrTStlicsia
IS helpful when detected, but it is by no means a
constant accompaniment of early disease, whilst in
severely to\ic cases it may also be absent

EXAMINATION OF THE PATIENT 43

Unimanual and bimanual palpation of the loins.—
This is of help in detecting renal or other loin-
swellings.

The finger-tips of one or other hand are pressed
forward under the ribs of the corresponding side of

44 DIAGNOSIS OF THE ACUTE ABDOMEN

the patient’s body. Resistance and tenderness with-
out swelling indicate rigidity and sensitiveness of the
quadratus lumborum and adjacent muscles, due
probably to a tender inflammatory focus near-by. A
perinepliric abscess, an inflamed l^idney, or a retro-
cjecal inflamed appendix may give this sign.

In bimanual palpation the observer brings tlie
other hand to the front of the loin, and can tlius
feel between the two hands any loin-swelling. A
pyo- or hydro-nephrosis or a lumbar abscess can
thus be detected. The patient should be asked to
take a deep breath so that any movement of the
swelling can be ascertained.

Determination of ilio-psoas rigidity.— It is ^vcl)
knorni that if there be an inflamed focus in relation
to the psoas muscle the corresponding thigh is often
flexed by the patient to relieve tlie pain. A lesser
degree of such contraction (and irritation) can be
determined often by putting the patient on the
opposite side and extending the thigh on the
affected side to the full extent. Pain nnll be
caused by the manoeuvre if the psoas be rigid from
either reflex or direct irritation. (Fig. 6.) The
value of the test is diminished if the abdominal wall
be rigid. The psoas-test is not so easily elicited
when the inflammation becomes subacute.

The estimation of liver-dollness is occasionally of
value. The dullness due to the liver is usually
obtainable in the right vertical nipple line from
the fifth rib to below the costal margin, and from
the seventh to the eleventh rib in the mid-axillary
line. If in a patient who has no signs or symptoms
of an atrophic liver, and in whom there is no abdo-
minal distension, a resonant note be obtained on

EXAiAIINATION OF THE PATIENT 45

percussing in the normally dull area in front, or if in
any case a resonant note be obtained in the normally
dull liver-area in the axillary line, then there must
be free gas in the peritoneal cavity due to the
rupture of stomach or intestine. (The rare con-
dition of pyo-pneumo-subphrenie abscess is usually
a late result of a ruptured stomach.)

The determination of liver-dullness anteriorly is
of no value in cases of great distension, for intestine
may be pushed up and cause resonance higher than
normal.

The deterniiaatiou of the existence of free fluid in
the abdominal cavity by the proving of movable
dullness is not of sucli great importance in diagnos-
ing acute abdominal disease. There are very few
acute abdominal conditions, in which there is not
some free fluid, and in those cases where there is an
easily estimable amount of fluid there are usually
other signs and symptoms which suffice. In the
writer’s experience it has seldom been necessary, and
often inadvisable, to attempt to determine it. Free
fluid in the abdomen may be serum, sero-pus, pus, or
blood. If there be enough blood in tiie peritoneal
cavity to cause movable dullness, it is unwise to
move the patient about, and haemorrhage should
be evident from other symptoms. In peritonitis,
with pouring out of a great deal of fluid, it causes
pain to move the patie/itf arid the test is usoahy
unnecessary.

In intestinal obstruction the determination of
free fluid is of some value and causes the patient
little inconvenience. One flank is percussed while
the patient lies on the back, and again after he Ims
been turned over on to the opposite side. If the

46 DIAGNOSIS OF THE ACUTE ABDOAIEN

note changes from dwII to resonant on changing
position free fluid is present The test is sometimes
vitiated by the accumulation of fluid mthin the
coils of obstructed mtestme Such fluid is often
great in amount and, owing to the atonj and
dilatation of the gut, moves easily from one part
of the abdomen to another with a changed position
of the patient

Examination of the pelvic cavity — As important
as the examination of the mam abdominal caMtj
is the investigation of the pehis The folIoiMng
methods should be employed m addition to the
previous examination

Supra pelvic palpation and percussion — This Mill
have been done generally m tlie usual abdominal
palpation, but it is well to pay special attention to
the supra pelvic region By pressing dccpl> behind
one or other Poupart s ligament, or behind the
pubis, one may detect either deep tenderness or a
lump or a certain muscular resistance significant of
deeper disease A full bladder or enlarged uterus,
a high pelvic abscess or an ovarian cyst, maj be
thus discovered

Rectal digital examination is extremely important
and informative The patient may he on the side
or the back (In peritonitis or hoimorrlnge it is
often univise to alter the position from dorsal to
lateral ) A rubber glove or finger stall should be
■worn The vs gtovtVj? vpi\.to

duced three or four inches up tlie rectal canal B)
pressing forwards, backwards, upwards, and later
ally, the whole lowei pelvns can be explored

Fonvards m the male one can detect an en
larged prostate, a distended bladder, or disease

EXA]\IINATION OF THE PATIENT 47

of the seminal vesicle. In tlie female one can
palpate painful and painless swellings of Douglas’
pouch, enlargements and displacements of the
uterus.

passing the finger well up ike canal, stricture
of the rectum due to cancer or fibrosis, or ballooning

Fio 7.— Diagram to illustrate method of performing obturator test.

of the canal below an obstruction can be ascertained.
The apex of an intussusception may sometimes be
felt.

It is important to test for tenderness on presstire
against the pelvic peritoneum. (See Fig. 15, p. 99.)

Bulging of a pelvic abscess against the anterior
rectal wall can readily be detected.

Laterally. — Tenderness due to an inflamed swollen

48 DIAGNOSIS OF THE ACUTE ABDOMEN

appendix or a small abscess on the lateral ^\all o(
the pel\ IS can be elicited
Posteriorly — Palpation ^ ill determine anj tumour
or inflammatory mass on the pyriformis, or in the
hollow of the sacrum

When the finger is withdrawn the presence on
it of blood, slime, or pus should be noted

In estimating the amount of pain caused b}
pressure upw ard on the pelvic peritoneum one must
not be misled by the patient’s expression of general
discomfort, but must ascertain tliat the pain is due
to pressure of the finger tip
Bimanual recto abdominal or vagino abdominal
examination will determine the presence and position
of any pel\ic tumour or swelling It is speciallj
important to note the size and position of tlic uterus
Any fullness m Douglas’ pouch should nc carcfullj
palpated

In infants a bimanual recto abdominal cxamma
tion enables one to explore the lower part of the
abdominal cavity thoroughly, and it may be possible
to manipulate an intussusception between the fingers
of the two hands

Thigh-rotation test * — When there is any inflamed
mass adherent to the fascia o\ er the obturator
internus muscle, rotation of the flexed thigli, so as
to put the irritated muscle through its full move
ments (especially internal rotation), will cause lijpo
gastric pam This sign sliould be tried especially
when rectal examination is difficult, or for any
reason inadvisable (Fig 7) The sign is positnc
when a perforated appendix, a local abscess, and

‘ Cope Tl e Obturator Test Bnl sf Journal of Surgrry

vol vii 1920

EXASIIJJATION OF THE PATIENT 49

occasionally when a haematocele is in contact with
the obturator internus, or when there is an accumu'
lation of inflammatoiy fluid in the pelvis.

.The chest should be thoroughly examined by the
usual methods of inspection, palpation, percussion,
and especially auscultation. By this means dia-
phragmatic pleurisy, early pneumonia, and pleural
effusion will be detected. The cardiac dullness must
also be determined and the cardiac sounds auscul-
tated.

Spine. — ^Any rigidity of or pain over the spinal
column should be carefully observed, especially in
children, in whom abdominal pain is frequently
complained of during the course of spinal caries.

Knee-jerks and pupils. — In an adult no examina-
tion of a patient suffering acute abdominal pain
is- complete without a testing of the knee-jerks and
the pupil-reactions. If the pupils or even one pupil
do not react to light, or if one or both knee-jerks
are absent, search must be made for other signs of
tabes so as to determine whether the pain is due to
a visceral crisis. Remember, however, that acute
abdominal disease may exist in a tabetic subject.

Brine. — The importance of examination of the
urine is well known, and constantly taught, but
though the precept be acknowledged the practice is
often at fault. The presence of blood, pus, albu-
min, sugar, and bacteria should be ascertained.
Not only is great fight often thus thro^vn upon the
diagnosis, but the finding of one or the other may
qualify prognosis and alter treatment. Before
operating on, and as a help in the diagnosis of, acute
abdominal disease, it is sometimes wise to pass a
catheter to ensure that the bladder is empty.

4

50 DIAGNOSIS OF THE ACUTE ABDOrEN

Blood-pressure. — "Hie estimation of the blood-
pressure is often of assistance in diagnosis of acute
abdominal crises. It is chiefly in cases of internal
hemorrhage, shock, and circulatory failure follo>\-
ing intestinal obstruction that a kno^\lcdgc of tlic
exact state of the blood-pressure is valuable. Both
the systolic and the diastolic pressures need to be
taken, for the most important figure to be knonn
is the difference between the t^^o, i.e. the pulse-
pressure, which indicates the reserve power in the
circulation. A low pulse-pressure is only found in
the most serious states oX collapse. '

Fig 9 — Kailiogrnm of ell'll
and abdomen of an infant
four daya old in whom eon
genital obstruction of

upper jejuDuni was corrrctlr

diagncB^ by Dr Gip* on
account of the gaseous Ow
tension of the ftomacli snJ
tlio fluid JeicN In the jc
junum.

X-ray examination. — IMtli the increase in f.icili-
ties for X-ray examination there is usually little
difficulty in obtaining a radiograph of the abdomen

Fto 8 — Radiogram thowtng
dilatation of araall mtestme
due to obstruction at the
ileo-cwcal junction Thepw
ture well demonstrates the
ladder pattern

EXAi\IINATION OF THE PATIENT 51

m cases ■\^hlcll may require it ]\Iuch information
may be obtained in cases of intestinal obstruction
Local distension of coils of intestine m an other-
ise undistended abdomen may point to small-bowel
obstruction, fluid levels may definitely demonstrate
a stoppage in the small intestine, and frequently
the outline of a distended colon vill sho^v the sur-
geon the exact site of the obstruction Most im-
portant of all in a case of suspected intussusception
an X-ray photo taken after the administration of
a barium enema a\i11 make the diagnosis certain.
(Figs 8, 9 and 25 )

Auscultation of the abdomen is occasionally of
use in determining whether the normal sounds due
to intestinal movements are to be heard If no
sounds due to movement are heard it follows that
the intestines are in a state of paralysis due to ileus
or peritonitis Sometimes thenature of the sounds
may help one to conclude that gas is being forced
through an obstructed bowel Occasionally friction-
sounds consequent on peritonitis may be heard
Very seldom does auscultation furnish information
which cannot be given by othei clinical methods

CHAPTER IV
APPENDICITIS

General considerahons.— If the mortality from
appendicitis is to be reduced almost to \anisliing
point, it IS essential that the earliest signs ^and
symptoms of the condition should be apprecufted
clearly , the vie\\ is accepted by most surgeons of
experience that ever} case of acute appendicitis
should be operated on within tlie first twenty four
hours from the onset, or as soon after as is possible
There are two reasons why cases are operated on
later than this — either the patient may tliink that
the symptoms are not serious enough to need
medical advice, or the medical adviser may tliink the
symptoms not typical of appendicitis or not serious
enough to demand operation It is clear that we
have no remedy against the first cause save the
education of the public, but in regard to tlic second
something can be done by way of explaining tliat
the so called typical symptoms of appendicitis as
given m the textbooks often indicate a sonicwiiat
advanced stage of the condition, and tint it is
impossible to say at the beginning of an attack
whether it is likely to be mild or sev ere in ty pc
It IS desirable and in most cases possible to
diagnose appendicitis before peritonitis Ims set in,
or at least before there is any more than tliat slight

63

APPENDICITIS

53

amount of congestion of the peritoneum which is
commonly associated with any inflammatory pro-
cess within the gut.

Pathological condition tn relation to symptoms , —
The different grades of inflammation of the vermi-
form appendix have for many years been well
described and understood, though there is still in
many quarters a lack of appreciation of the ad-
vanced pathological condition often coexistent with
the initial symptoms, or at any rate n ith the initial
complaint Catarrh of the mucous membrane,
parenchymatous inflammation of the uhole wall,
gafigrene of the interior lining or of all but the
peritoneal coat, any of these may coexist with
symptoms so slight (but not indefinite) that they
may be overlooked by the patient and tliought of
slight significance by the hurried and unobservant
onlooker Even rupture of the appendix due to
local gangrene may not cause the patient to he up
so long as local adhesions prevent the extension of
the mischief. When the appendix ruptures into
the general abdominal cavity m the absence of any
protective adhesion, or when after being localized
the inflammatory process extends, not even the
most stoical or insensitive jiatient can refrain from
seeking advice and taking to bed

Obstruction of the lumen of the appendix, either
bj a concretion, stricture, kmk, or adhesion, is
usually accompanied by more acute and severe
symptoms. So definite is the difference that some
describe two forms of tlie disease — acute appendi-
citis and acute appendical obstruction So far as
this differentiation tends to emphasize the usually
greater urgency of symptoms with obstruction of

Pio. 10 —Diagram to eboir thevainoua poe«iblo positionj of llie aff-rndi*
^cnDifonnH

When the appendix has ruptured tlic pathological
condition is not merely appendicitis, but peritonitis
—local, diffuse, or general as the case may be — and

APPENDICITIS

55

diagnosis is to that extent more complicated. It
is frequently only by careful attention to the history
tliat one can make certain as to the true cause of
such peritonitis.

Anatomical position of the appendix in relation
to symptoms . — ^The vermiform appendix, tJjough
usually described as being situated behind the ileo-
cfecal junction with the tip directed towards the
spleen, is not by any means always found in that
situation when it is diseased and sought for by the
surgeon. The realization of the common positions
is of great importance in diagnosis, for the signs and
symptoms vary considerably in the various posi-
tions. The accompanying diagram shows the more
common positions. (Fig. 10.) For descriptive pur-
poses it IS well to recognize the ascending appendix,
the iliac appendix, and the pelvic appendix. It is
clear that when the appendix lies by the side of the
ascending colon, or in the iliac fossa, there will be
the most definite local signs, whilst if it be situated
behind the cascum, or behind the end of the ileum
and the common mesentery, the inflammatory
process ivill be somewhat masked by the gut lying
in front. If the appendix hangs over the right
brim of the true pelvis the disease may give rise
to few signs in the supra-pubic region of the abdo-
men, and a dangerous condition results to which
we shall call attention below.

Very many, if not most, of the mistakes made in
the diagnosis of appendicitis are due to a failure
to realize the very great difference in signs and
symptoms which follow from the varying position
and relations of the appendix.

56 DIAGNOSIS OF THE ACUTE ABDOMEN

DIAGNOSIS OF APPENDICITIS BEFORE PERFORATION
HAS TAKEN PLACE*

In any case of suspected appendicitis one must
coasider carefully :

(A) The history immediately prior to the
onset of pain

(B) The symptoms of the attack and the
local signs

(C) The order of occurrence of the symptoms

The local conditions are more variable and

notable after perforation has taken place, but tlicre
are definite indications even before perforation.

(A) There IS frequently a histonj of indigestion,
“ gastritis,” or flatulence for a fen days prior to the
onset of the attack. In a patient nho Jms never,
or seldom, been subject to pain after taking food,
this history should be sufficient to put one on guard
It may be elicited that frequent slight attacks of
pain have been cApenenced in tlie appendicular
region.

A history of unusual irregularity of the bonds is
often obtained Sometimes there is constipation,
at other times diarrhoea, especially in children
The occurrence of diarrhoea is likely to mislead
It is probably due to the actiiity m the cjccum and
colon of the Mrulent microbes nliich cause sucli
damage to the appendix In some cases an in-
flamed pclMc appendix may irritate t/ie rectum.
The early diarrhcea has to be distinguished from the
late variety due to irritation of the rectum by pch ic
peritonitis or a peh ic abscess

* VideZ Cope, “ The PrepentonitieStogcof Acute Appcndifitli.’*

Brit Mtd Joum 1014

APPENDICITIS 57'

(B) The symptoms and hdal signs of the attack.—
The signs and symptoms are ;

Pain (epigastric, then right iliac).

Vomiting— nausea — acute loss of appetite.

Local deep tenderness (per abdomen or per
rectum).

Local rigidity of muscles (inconstant)

Local distension (inconstant).

Superficial hypera^thesia (inconstant).

Fever.

Constipation.

Testicular symptoms (uncommon).

Fain. — The pain in the majority of cases is fir.st
referred to the epigastric or umbilical region, and
only later is localwed in the right iliac fossa. Occa-
sionally the initial pain is felt “ all over the abdo-
men,” though that is more usual in cases ^yith perfor-
ation. Sometimes the pain is from the first hypo-
gastric. IMien the-appendLx is retrocxecal in position
the initial pain may be felt in the right iliac region.
Though, therefore, the pain commonly starts in the
upper part of the abdomen, this is not invariable.

The causes of the early pain are probably t^vo.
First and most important is the exaggerated
peristalsis of the appendix, excited by the relative
or absolute obstruction to its lumen by a concretion,
kink, or swollen mucous membrane ; bacterial
infection causes the accumulation of irritating
products which leads to a distension of the appen-
dical lumen. Secondly, the upper abdominal pain
may be due to reflex pyloric spasm. *

The epigastric pain is most acute and distinct in

58 DIAGNOSIS OF THE ACUTE ABDOMEN

those cases where there is considerable obstruction
to the appendical lumen. The localization of the
pain to the right iliac region usually takes place
some hours after the onset of the diffuse pain in the
epigastric or umbilical regions.

Fio II — Djagram to *how (1) comraon positiooa of mitiol referred painj
(2) position of deep tenderness (nearly always to bo eheitetl when
abdominal wall not rigid) , (3) shaded area to mark out the iliae
triangle of byperssthesia m many coses of appendicitis

Vomiting— Nausea— Anorexia.— Vomiting gen-
erally occurs in the early stages of tiic attack,
but usually a few hours after the initial jiain.
Many patients do not vomit, but instead have a
sensation of nausea. I^ss of appetite or repulsion
for food may be regarded as a lesser degree of the

APPENDICITIS

59

same sensation and often of equal value in diagnosis.
Anyone in previously good health nho suddenly
develops anorexia and complains of abdbminal
pain should be carefully watclied for appendicitis.
The degree of nausea and the frequency of vomiting
in the early stages appear to depend on two factors
— first, the amount of distension of the inflamed
appendix , and secondly, the reflex nervous sus-
ceptibility of the patient Vomiting is the more
prone to occur m children, or in patients whose
digestive tract is easily deranged

It may be taken as an important general rule that
the levcrity and frequency of the vomiting at the
onset of an attack of appendicitis indicate the
degree of distension of the appendix and conse-
quently the immediate risk to the patient that
perforation may occur

Local deep tenderness over the site of the appendix
IS to be elicited almost from the onset of the attack,
but at first it is frequently masked by the more
generalized referred pains IVlien the latter have
subsided the local deep tenderness is easily elicited
Occasionally even careful palpation cannot detect
any spot of local tenderness in the iliac fossa during
the initial stage of appendicitis The place ^\he^e
deep tenderness can almost always be detected is
a spot just below the middle of a line joining the
anterior superior iliac spine and the iimbihcils
This roughlj corresi?onds to the position of the base
of the appendix Tenderness over MacBurney’s
spot IS not so constant. This tenderness appears
to be located actually m the appendix itself, for
the site of the pain on pressure varies somewhat
according to the position of tlie appendix, and is

58 DIAGNOSIS OF THE ACUTE ABDOMEN

those cases where there is considerable obstruction
to the appendical lumen. The localization of the
pain to the right iliac region usually takes place
some hours after the onset of the diffuse pain in the
epigastric or umbilical regions.

Fio 11 — Diagram to ahovr (!) common poaitions of mitml referred palnj
• (2) position of deep tendemeee (nearly alwajs to bo elicited wlien

abdominal wall not rigid), (3) shaded area to mark out the ilisc
triangle of hyperKsthesia m many coses of oppcndicitii

Vomiting — Nausea — Anorexia. — Vomiting gen-
erally occurs in the early stages of the attack,
but usually a few hours after tlic initial pain.
Many patients do not vomit, but instead have a
sensation of nausea. TjOss of appetite or repulsion
for food may be regarded as a lesser degree of the

APPENDICITIS

59

same sensation and often of equal value in diagnosis.
Anyone in previously good health ^\ho suddenly
develops anorexia and complains of abdominal
pain should he carefully watched for appendicitis.
Tlie degree of nausea and the frequency of vomiting
m the early stages appear to depend on two factors
— first, the amount of distension of the inflamed
appendix , and secondly, the reflex nervous sus-
ceptibility of the patient Vomiting is the more
prone to occur in children, or in patients whose
digestive tract is easily deranged

It may be taken as an important general rule that
tlie •everity and frequency of the vomiting at the
onset of an attack ot appendicitis indicate the
degree of distension of the appendix and conse-
quently the immediate risk to the patient that
perforation may occur

Local deep tenderness o\ er the site of the appendix
is to be elicited almost from the onset of the attack,
but at first it is frequently masked by the more
generalized referred pains When the latter have
subsided the local deep tenderness is easily elicited
Occasionally even careful palpation cannot detect
any spot of local tenderness in the iliac fossa during
the imiial stage of appendicitis Tlie place vherc
deep tenderness can almost always be detected is
a spot ]ust below the middle of a line joimiig the
anterior superior iliac spine and the umbilicus
This roughly corresponds to the position of the base
of the appendix Tenderness over MacBumey’s
spot is not so constant This tenderness appears
to be located actually m the appendix itself, for
the site of the pain on pressure varies somewhat
according to the position of the appendix, and is

bO DIAGNOSIS OF THE ACUTE ABDOMEN

obtainable when that viscus is not adherent to
anj' surrounding part Sometimes the tenderness
may be due to adjacent peritoneal irritation The
spot of maximum tenderness may sometimes be
accurately located by gentle percussion o\er the
affected region In the case of an appendix situated
m the pelvis a rectal examination vail frcquenth
elicit pain on pressing on the inflamed organ
Local hypersesthesia of the skin of the abdominal
wall IS a frequent, but not a constant, accompani-
ment of an inflamed unperforated appendix It
can be demonstrated in over half the cases of
appendicitis Though occasionally bilateral, it is
usually confined to the right side The areas
affected nearly always lie m the area of distribution
of the nerves from the tenth, eleventli, and twelfth
dorsal and first lumbar spinal segments Tliough oc-
casionally a zone of hyper'esthesia may be found
extending from the middle line m front back to the
spine, yet as a rule only tlie anterior part of the
abdominal vail is affected Sometimes the right iliac
“ appendix triangle ” (Sherren) is demonstrable, at
other times only a part of such triangle is li}q>cr
aesthetic (Sec Fig 12) As Sherren Ins pointed out,
hyperacsthcsia depends largely on the degree of dis-
tension of the appendix A common place in vlucli
it can be elicited is a circumscribed area just to the
right of and on a loel vith the umbilicus Some
times the sensitne area is slightly lover than this,
but generally it lies in the area of distribution of the
tenth and ele\ enth thoracic spinal segments When
there has been any local peritonitis m tlic iliac fossa
one can frequently elicit a band of hj pcrTstlicsm im-
mediately abo\ e and parallel to Poup irt’s ligament

APPENDICITIS

61

Local muscular rigidity over the inflamed area is
frequently present, but is by no means a constant
symptom in the initial stages. There are several

FiOi 12.— -Types of hypersstltesia (to pm stroke) xrhicli may be found in
cases of acute and subacute appendicitis.

grades of muscular rigidity. The extreme degree
is that in which the particular section of the ab-
dominal wall is persistently stiff and will not move
on respiration, in a lesser degree the muscle stiffens

62 DIAGNOSIS OF THE ACUTE ABDOMEN

almost as soon as the hand touches the skin, and in
the least degree the rigidity occurs only (and that to
a slighter degree) Avhen the fingers are pressed more
deeply into the iliac fossa or tow ards the appendix
In most cases extreme muscular rigidity coincides
with commencing peritonitis, and e\en slight
degrees, nhen persisting, are due to irritation of the
parietal peritoneum It is a common e\perience to
find no local muscular rigidity in a case of appen-
dicitis without any peritonitis In making tins
statement it must be understood that great care
should be taken to exclude the rigidity whicli man)
patients develop as a result of nenousness and
apprehension, or which may be induced by a rougli
or cold examining hand Certainly witli an im-
perforated appendix situated m the pch is ngiditj
of the abdominal wall is nearly aluays absent
Failure to realize this important fact is respon
sible for manj delayed operations and lost Incs
An appendix may he on the point of bursting into
the general peritoneal cavity without a single ad-
hesion to limit infection, though at the same time
the abdominal xvall may be flaccid and alloxv a free
manipulation without any rigidity appearing 'llns
fact must be knoun to every surgeon of experience,
but in general it is certainly not fully appreciated,
nor do the textbooks make the point clear
Rigidity IS taught to be one of the earliest signs of
acute inflammation of the appendix, wlicreas in
quite a large proportion of cases it is almost com-
pletely absent in the earliest stage, and in some cases
IS absent even though pehic peritonitis exists
When the inflammation of the appendix has
caused oedema of the contiguous portions of the

APPENDICITIS

63

abdominal panetes {whetlier posterior, Intcial, or
anterior) muscular rigidity is the rule

Rigidity of the psoas should always be tested for
by extending the right thigh with the patient on the
left side Rigidity of the quadratus lumborum
should be present uith an miiamed ascending
appendix It is difficult to ascertain, but may be
surmised if deep resistance be felt on pressing the
fingers fon\ard fiom beneath the loMer posterior
costal margin.

Fever may not be present at the beginning of the
attack, but nearly always develops before twenty-
four hours ha\e passed Before rupture has oc-
curred the temperature does not usually go much
above noimal, two or three degrees Fahrenheit being
the average elevation Mistakes are liable to be
made owing to the fact that the temperature is not
elevated at the time of the onset of the pam, and
thus the more serious disease may be mistaken for
an attack of simple intestinal colic In any sus-
pected case the temperature should be taken e\ ery
tuo or four hours, and if it rise in a gradual manner
it IS a point in favour of appendicitis If at the \ ery
beginning of any attack of acute abdominal pain
the temperature is considerably raised (i e 103® F.
or 104® F.), the presumption is against appendicitis
Very rarely the illness may start with a rigor.

Though the patient frequently complains of con-
stipation, yet numerous cases occur in which an
attack of diarrhoea ushers m the attack.

Tiie pulse is only slightly, if at all, acccleiated in
the early stage , it may be normal m every way,
even though the temperature be raised. Any con-
tinned or decided acceleration of the pulse cither

64 DIAGNOSIS OF THK ACUTE ABDOJIEN

corresponds -zvith the occurrence of local peritonitis
or indicates an appendix distended zvitk infective
material ; to wait for such alteration is therefore
to sacrifice the best time for operation.

When the appendix is acutely inflamed gaseous
distension of the ccecum is frequently present ; this
local distension is due partly to the excessive forma*
tion of gases by the active bacterial decomposition
of the contents of the csecum and appendix, and
probably in some cases partly to an accompanying
inflammation of the interior of the cjecum (typhlitis)
with atony of the gut. It Is more likely to be
present when the appendix is retrociccal in position
and closely embedded in the wall of the crccum. It
gives rise to a local swelling with a tympanitic note
on percussion, to borborygmi, and occasionally to
painful peristaltic waves. This may cause the
observer to think that he is merely dealing with a
case of caecal dyspepsia, and the swelling of the
c«cum may mask the inflamed appendix placed
behind it ; or the painful contractions of the
distended gut attempting to empty itself may even
suggest intestinal obstruction.

In the male, testicular symptoms are some-
times produced by an inflamed appendix even
when unperforated. There may be pain in either
right or left testicle, or in both, or the patient may
say that the right testicle was retracted at a certain
stage of the disease- The pain may possibly be
due to irritation of the sympathetic filaments
accompanying the spermatic artery, but it is more
likely that it is a pain truly referred from the
appendix since the tenth dorsal spinal segment
apparently supplies both viscera. The direct stimu-

APPENDICITIS Go

lation of tlie genito-crural nerve by inflammatory
exudate might account for testicular retraction.

(C) The order of occurrence of the symptoms. — This
is of utmost importance in diagnosis. It is largely
due to Murphy that the significance of the sequence
of symptoms has been realized. The march of
events is :

(1) Pain, usually epigastric or umbilical.

(2) Nausea or vomiting.

(3) Local iliac tenderness.

(4) Fever.

(5) Leucocytosis.

Murphy stated : “ The symptoms occur almost
without exception in the above order, and when that
order varies I always question tlie diagnosis.”
Everyone who has carefully investigated the point
must be able to confirm this dictum, though it must
be allowed that occasional exceptions occur. If
fever precedes the onset of pain, if vomiting accom-
panies or precedes the first bout of pain, it is gener-
ally not appendicitis with which we are dealing.

It is a fact worthy of remembrance that an acute
attack of appendicitis often starts in the middle
of the night, and may awaken the patient out of
sleep.

There are two or three facts about the retro-
cjecaf appendix that need special mention. Pain is
usually less, and is often from the first felt only
locally. Vomiting is not so frequent, and generally
the muscular rigidity over the diseased focus is less
than would be expected for so advanced a lesion.

The diagnosis of appendicitis in the stage prior

5

66 DIAGNOSIS or THE ACUTE ABDOMEN

to perforation depends therefore upon certain
constant and other inconstant features Epigastric
pain, nausea or vomiting, right iliac pain and fe\er
in that symptom sequence, are almost constant, and
local tenderness, either on deep pressure in the right
iliac region or by rectal examination, is im ariable
Local rigidity is common, but not constant The
other symptoms mentioned above are inconstant,
whilst the pulse rate is usually normal and may
mislead seriously

DIAGNOSIS AFTER PERFORATION HAS OCCURRED

It IS to be regretted that so great a number of
cases of acute appendicitis come to the surgeon after
the appendix has perforated at the site of a patch of
gangrene One reason for this is tint practitioners
who send cases to surgeons are not always able to
see the operations performed and consequent!) fail
to realize that the symptoms of appendicitis as
described in nearly all textbooks are those winch
accompany appendicitis Avjth perforation of the
appendix It is the rule for practitioners to be
surprised at the advanced state of the patiiologicaJ
process in cases w here they thought they w ere ad\ is*
ing an early operation It is from tliose doctors who
see their cases operated on that tlie early cases come
Local abscess means perforation of tlie appendix,
and some esinnate may Wins ba ^ tVw.

relative proportion of perforated and unperforated
cases In hospital practice probably tlie proportion
of perforated and unperforated cases w ould be about
equal In private practice one obtains a laiger
proportion of unperforated cases It must be

APPENDICITIS

67

allowed that in a few cases the first symptoms that
the patient complains of seem to be those due to
a perforation, but these cases are the exceptions

The symptoms and course of illness consequent
on appendicitis with perforation of the appendix
are those already described, with the addition of
the symptoms due to local or diffuse peritonitis
There are usually an accession of pain and renewal
of vomiting when the perforation occurs, but the
exact symptoms vary according to the position of
the appendix and the nature of the protective
peritoneal reaction

Round the perforation itself a localized abscess
may form, but sometimes a piece of omentum may
seal the opening, or, more rarely, the infection may
spread quickly and widely without tlie formation of
any or many adhesions A definite lump is gener-
ally indicative of a perforation In the absence of
a perforation a lump may be caused by a thick and
oedematous ccecum

There are two mam divisions of the pathological
states consequent upon perforation depending upon
the position of the appendix itself (1) when the
appendix is above the bnm of the true pelvis ; (2)
when the appendix hes wholly or m part m the true
pelvis.

(1) The ihac appendix. — ^\Vhen an appendix lying
above the pelvic brim ruptures there 11111 be found
on examination either a definite tender lump, a very
definite rigidity of the abdominal ii all o\ er the site
of the diseased viscus, or both rigidity and a lump.

In addition there will be fever (higher as a rule
than before perforation), hypericsthesia of the skin
of the abdominal ivali m the right iliac or right

6S DIAGNOSIS OF THE ACUTE ABDOMEN

lumbar region, and certain localizing signs varjing
according to the position of the appendix.

{a) When the appendix perforates retrocascallv
there will be a lump which may be resonant on
percussion, o^\lng to the intervening ciecum. Tiie
infection will cause inflammatory oedema of the
iliacus and quadratus lumborum and adjacent parts,
and tenderness will be elicited on pressing the
fingers forward below the right costal margin at the
outer border of the erector spime.

(b) The appendix may he in a position parallel
with the csecum and ascending colon, but lateral to
them The symptoms are then similar to those
just described, save that rigidity of the lateral and
anterior abdominal wall is more evident, and that
any lump is more easily felt because the crccum does
not mask it

(c) The conditions resulting from perforation of
an appendix lying in the iliac fossa on the ilmcus or
psoas a’’e sufficiently characteristic Immediately
after the perforation there will be intense rigidity
of tlie abdominal wall over the right iliac region and
great tenderness on pressure over the same area
(Very rarely, chiefly m patients suffering from severe
toxic absorption, rigidity which had at first been
present disappears on perforation of the appendix.)
After a certain time, if suitable resistance is offered
to the infection, the peritoneal reaction becomes
hoiited, and the ngidtty usuaWy diminis)ics some-
what, allowing the palpating hand to feel a tender
lump — either due to a small local abscess or a mass
of omentum wapped round the inflamed perforated
appendLx.

There are ti\o special sjmptoms uhich may help

APPENDICITIS

69

exact localization in this region. The irritation
and reflex rigidity of the ilio-psoas frequently cause
the patient to hold the right thigh flexed, or witli a
lesser degree of irritation pain may be felt only if
the riglit thigh be fully extended as the patient lies
on the left side. This sign is often of great value.

In a few cases irritation of the external cutaneous
nerve as it crosses the iliacus is evidenced by pain
and hypersesthesia along the distribution of that
nerve.

(d) When the appendix lies so that the tip is
directed medialwards the result of its perforation
varies greatly according to whether it is behind or
in front of the ileum. If behind the ileum localiza-
tion of the inflammatory process usually results, but
the swelling is not so readily felt since the ileum
covers and masks it. But tenderness and rigidity
may be present, and an indefinite lump may be
felt, whilst the test for psoas-irritation may help
in diagnosis.

The ureter crosses the pelvic brim in close re-
lationship to the medially directed appendix, and
occasionally pain on micturition may be produced
presumably by irritation of the ureter.

If the appendix perforates whilst lying in front
of the ileum there is great danger of very extensive
peritonitis, but if the infection becomes localized
diagncusis is fairiy easy, for the formatic^ of pus
close up against the abdominal wall leads to local
boardlike rigidity and exquisite tenderness (hyper-
algesia) over the affected area. Psoas-irritation
will be absent,

(2) The pelvic appendix. — The early symptoms
of an attack of appendicitis wlien tije appendix is

70 DIAGNOSIS OF THE ACUTE ABDO'NIEN

situated m the pelvis are similar to those T\hich
ensue when it is situated above the pelvic brim,
vith the exception that rigidity of the right iliac
region of the abdominal wall is seldom present
in the early stages, and that the pain is more
frequently felt in both left and right iliac foss®
Pam is not so readily localized m the right iliac
fossa, but is always felt on deep pressure at the
bnm of the true pelvis, and the epigastric pain
may dominate the scene for a longei time

The perjoraied pelvic appendix is one of the most
easily overlooked, and therefore one of the most danger-
ous conditions which may occur in the abdomen The
reason appears to be as follows Whilst the np»
pendix IS unruptured and tense the pain due to the
distension and penstaltic contraction is definite and
se^ere, and is felt chiefly m the epigistrium or urn
bilical zone ^Vhen rupture occurs tlic epigastric
pain diminishes and local pelvic peritonitis results
on the right side of the pelvis or at the bottom of
the pelvic pouch of peritoneum This is usually
unaccompanied by ngidily of the loo-er abdominal
muscles, and since the pain of appendicular (hs
tension has ceased, and the pam due to pelvic
peritonitis at this stage is frequently v cry insignifi
cant, the patient tnay seem better, and the examina-
tion of the abdomen may give little indication of
the trouble m the pelvis Sooner or later— usually
within three or four days — the peritonitis cither
becomes definitely localized into a pelvic abscess of
considerable dimensions, or the inflammation may
track upwards towards the general abdominal
cavity and give rise to increasing pain, distension,
and rigidity of the abdominal wall If from the

APPENDICITIS

71

fact that the patient came late for advice, or that
sufficient attention was not paid to the preliminary
symptoms and symptom-sequence, the pre-rupture

stage of the inflamed pelvic appendix is missed, it is
at least essential to diagnose the ruptured appendix
ns soon as possible after rupture before peritonitis

72 DIAGNOSIS OF THE ACUTE ABDOMEN

has extended too far upwards into the abdominal
cavity. For this purpose it is important to pay
attention to the anatomical position of the pelvic
appendix, which lies in relationship with one or more
of the follo^\’ing — the pelvic wall, the rectum, and
the bladder. Irritation of the bladder or rectum mav
be signified by frequency of or pain during micturi-
tion, or by diarrhcea or tenesmus respectively. But
more ‘important is the fact that usually a tender
swelling can be felt against the right pelvic wall by
the finger inserted into the rectum. Moreover, when
the ruptured appendix is adherent to tlie fascia
covering the obturator internus and the subjacent
fibres of the muscle are affected by the inflammatory
cfidema, rotation of the flexed thigh so as to put
the muscle through its extreme movements (especi-
ally internal rotation) will cause hypogastric pain.
In performing this manoeuvre it is essential that
the thigh be flexed so as to relax the psoas muscle.

. By a careful consideration of the history and of
the points just mentioned it should be difficult to
miss the early inflamed pelvic appendix. The
appendix which is most likely to give rise to doubt
in diagnosis is one situated high up in the right
posterior quadrant of the pelvis, for in this situation
there may be no localizing signs and it may be
difficult to feel the viscus per rectum.

The later symptoms resulting from rupture of a
pelvic appendix are either those of a large pelvic
abscess or those of advanced pelvic and hypogastric
peritonitis, with increasing toxaemia. Tenderness
and rigidity of the w’hole lower abdominal wall,
distension, vomiting, and increased pain, all give a
clear picture of peritonitis.

APPENDICITIS

• 73

It is noteworthy that as the peritonitic inflam-
mation spreads upwards from the pelvis it does so
frequently on the left side first. This is probably
because as the pelvis fills with pus the anatomical
path of least resistance is by the side of the sigmoid
colon.

When a pelvic' abscess has formed there are
usually all the symptoms of suppuration — fever,
furred tongue, anorexia, and leucocytosis, whilst
locally there are tenderness and slight distension in
the hypogastrium. Rigidity of the lower abdominal
wall is quite frequently absent, even when a pelvic
abscess is present. Occasionally the temperature
may be normal even though an abscess be present.

Per rectum tlie bulge of tlie abscess can easily
be detected, and pain is produced by pressing on
the bulging mass.

In women the intervention of the uterus makes
bladder-symptoms less likely to supervene in cases
of appendicular suppuration. The normal uterine
loss may be increased by the pelvic congestion and
the menstrual period may be precipitated thereby.

There is a rare condition of intestinal obstruction
which is said to be produced by pelvic appendicular
suppuration at a late stage. Both the sigmoid
colon and the small intestine may be obstructed
within the pelvis. Mr. Handley has termed the
cDuditjnu ileus duplex. But if the inflamed pelvic
appendix were diagnosed in tlie early stage there
would never arise any such dangerous late complica-
tion. In early diagnosis and operation lies the
prevention of such conditions.

CHAPTER V

THE DIFFERENTIAL DIAGNOSIS OF

appendicitis

Diagnosis of appendicitis is usually easy. Con-
siderably over 50 per cent, of the acute abdominal
emergencies admitted to a hospital are cases of
appendicular inflammation. So frequent is the con-
dition that it would almost appear tliat some do
not trouble to attempt a differential diagnosis, since
many mistakes are made which might easily be
avoided by a careful examination.

The typical case with epigastric pain, followed
by vomiting, succeeded by localizing of the pain in
the right iliac fossa where tenderness con always
and rigidity of the overlying rectus can usually be
made out, is sufficiently characteristic, even without
the presence of slight fever, to make tiie diagnosis
certain. But there are certain difficulties wliich
need to be discussed.

It is important first to make quite sure that one is
dealing with a primarily abdominal condition. In
the course of a definite attack of influenza abdominal
pain may ensue, and during an outbreak of the
disease there is grave danger that occasionally an
attack of appendicitis may be overlooked and
attributed to “ abdominal influenza.” But seldom
in influenza is the abdomen alone attacked, and a

74

DUGNOSIS OF APPENDICITIS

75

local examination will usually determine whether
the site of the pain be appendicular. Yet pain and
tenderness in the right iliac fossa are sometimes
present m influenza, though the abdominal pain
is more likely to be general, and borborygmi
may sometimes be heard all over the abdomen
Backache and pain in the eyeballs are more likely
to be felt m an attack of influenza and vomiting
may precede the abdominal pain — a sequence seldom
seen in appendicitis

Again, one must always exclude diaphragmatic
pleurisy or early basal pneumonia before diagnosing
appendicitis Pam, tenderness, and muscular
rigiditj may all be noted m the right iliac region
m thoracic disease, but sometimes firm continued
pressure will enable one to feel deep into the iliac
fossa ■without causing any increase of the pam.
In cases of appendicitis pressure over the left iliac
fossa earned out by fingers pressed deeply m and
directed towards the right side will sometimes cause
pain in the appendicular region — a sign which is
absent in cases of pleurisy or pneumonia In
thoracic disease the respiration rate is usually in-
creased, and the pulse respiration ratio diminished
Of course, a careful examination of the chest is the
method of discrimination

Very rarely spinal disease may cause pam referred
to the appendicular region An examination of
the spinal column can easily and quickly be made,
and would soon determine any lesion On one
occasion I ha\c known osteomyelitis of the ilium
simulate acute appendicitis In this case the boy
looked \ery ill, had fever and local ihac pain, but
there was no muscular ngidit\

76 DIAGNOSIS OF THE ACUTE ABDOMEN

Typhoid fever is another general disease hicli is
occasionally mistaken for appendicitis, because of
the abdominal pain and tenderness ^\Illch are some-
times localized in the right ihac fossa In most
cases, however, there are general symptoms >vhich
nould enable the diagnosis to be made Headache,
general malaise, enlargement of the spleen, presence
of a roseola, and the absence of the acute onset so
usual in appendicitis, should make one suspicious
of typhoid, and the absence of a leucocytosis nould
exclude appendicitis In children in nliom the
general symptoms of typhoid fe^ ei are often slight,
and occasionally m adults attacked by tlie ambula-
tory type of the disease, mistakes might be made.
In some doubtful cases the presence of definite
cutaneous hyperaesthesia \NOuld decide m fiNour of
appendicitis

A true typhoid appendicitis is sometimes seen.
I once operated on a lad who had typical symptoms
of appendicitis, and removed an appendix crondwl
with thread worms and ha\ ing an ulcerated mucous
membrane The pathologist who examined the
appendix stated that he hod ne^er previous!} seen
ulceration caused by thread Morms alone Hie
child’s temperature kept up m an irregular manner
after operation, and an agglutination test to the
bacillus typhosus proved positive Tins kind of
case, in which the symptoms of a true t} phoid
appendicitis initiate the iUac^s, is uncommoN
If the symptoms ha\c been present for a «eek
when the patient is first seen the agglutination-
reaction may be positive in respect to *->
typhosus or paratypliosus a or b A
of a typhoid patient might pro\c

DIAGNOSIS OF APPENDICITIS

77

within the first week of tlie disease. One must
utter a warning against'treating any doubtful case
as typhoid without making a rectal examination.
The irregular fever, tympanitic abdomen, and vague
hypogastric pains which accompany a pelvic abscess
may be and have been mistaken for typhoid fever,
but a finger inserted into the anal canal wdll serve
to distinguish.

In the stage of catarrhal appendicitis before
there is any or much congestion or inflammation of
the peritoneum, and when muscular rigidity is
often if not usually absent, appendicitis is sometimes
mistakenly diagnosed as :

A bilious attack.

Indigestion.

Colic.

Gastritis.

The fact that the initial pain is frequently felt in
the epigastrium is responsible for the diagnosis of
gastritis or indigestion. The sudden onset, often
without any relationship to food-taking (e.g. in the
middle of the night), together with tlie gradual
localization of pain in the right iliac fossa, and the
onset of slight fever, should give sufficient ground
for a diagnosis. The danger is that with such slight
symptoms the observer may not even make a
thorough abdominal examination, or may omit a
rectal examination whereby an inflamed pelvic
appendix might be diagnosed.

When vomiting or nausea is a notable feature of
the attack it is sometimes erroneously attributed
to a bilious attack. This is especially the case with
children, in whom such a diagnosis must always be

78 DL4GN0SIS OF THE ACUTE ABDOMEN

carefully made, and only after appendicitis iias been
fully excluded It is a common experience for the
surgeon who has removed a gangrenous appendix
from a child’s abdomen to be told by the parents or
practitioner that the child had always been subject
to bilious attacks, for one of which attacks the acute
illness had at first been mistaken Any child,
previously in good health, who is suddenly taken
with abdominal pain and loss of appetite, has
nausea, or vomits, and at the same time shows
definite deep tenderness m the right iliac fossa, even
if the pulse be normal and the temperature not cle
vated, IS most probably suffering from appendicitis
Before a diagnosis of xniesUnal colic be made
appendicular colic must be excluded If a few
hours after the onset of the pain there still be
no tenderness elicited on pressing over the right ihac
fossa or right pelvic brim, and none on the right side
of the pelvis (by rectal examination) it niaj fnirl}
be excluded In simple colic pressure on the pain-
ful part often relieves the pain

When the local signs and symptoms of appen-
dicitis are well developed (pain, tenderness, Iijper-
jcsthesia, rigidity) there are very many conditions
which have to be excluded, and for which it may be
mistaken ^Vhen. the local signs arc verj clear tlie
appendix is usually either perforated or m danger
of perforating To catalogue the diseases which
may simulate or be swnvslwted by appewdievUs is to
enumerate all the chief acute abdominal diseases
This IS obviously of little practical value It will
be better, therefore, to give only the more common
conditions causing mistakes and to group them
according to tlie position of the appendix

DIAGNOSIS OF APPENDICITIS 79

The ascending appendix (Eetrocsecal or
Paracsecal) :

Cholecystitis.

Inflamed duodenal ulcer.

Perforated gall-bladder.

Perinephric abscess.

Hydronephrosis.

Pyonephrosis.

Pyelitis.

Stone in the kidney.

Iliac position of appendix :

Leaking duodenal ulcer.

C®cal or ileo-c®cal carcinoma.

Psoas abscess.

Ileo-csecal tuberculosis.

Hip disease.

Tuberculous ileo-c«cal glands.

Pelvic position of appendix :

Stone in the ureter.

Intestinal obstruction.

Diverticulitis with abscess.

Perforation of a typhoid ulcer.

In women ;

Ectopic gestation.

Twisted ^pedicle of an ovarian cyst or of a
hydrosalpinx.

Rupture of a pyosalpinx.

Salpingitis.

Before diagnosing appendicitis in tropical climes
one would also have to exclude :

so DIAGNOSIS OF THE ACUTE ABDOMEN

Amoebic typhlitis.

Hepatitis.

Leaking liver-abscess.

Malaria.

When the local manifestations have spread widely
and the patient first comes under observation with
generalized peritonitis, it is necessary to distinguish
the condition from all the various causes ^vhich may
lead to such a pathological picture.

Late cases mth extensive peritonitis must be
distinguished from :

Acute intestinal obstruction. (See
Chapter VII.)

Thrombosis or embolism of mesenteric
vessels. (Seep. 130.)

Acute pancreatitis. (See p. 111.)

Pneumococcal peritonitis. (See p. 229.)

Pylephlebitis.

General peritonitis (ruptured gastrici
duodenal, typhoid ulcers, etc.).

DIFFERENTIAL DIAGNOSIS OF THE PERFORATING OB
PERFORATED ASCENDING APPENDIX

The gall-bladder, the duodenum, and tlie kidney
are the viscera in anatomical proximity to the
ascending appendix, and inflammation of tlieni or
their surroundings may cause difficulty in diagnosis.

Cholecystitis may very closely simulate appendi-
citis. Pain, vomiting, fever, constipation, and local
tenderness on the right side of the abdomen
present in both cases. An enlarged inflamed ^ *
bladder frequently comes down into the
lumbar region, but more usually enlarges in tt
direction of the umbilicus. In tliin subjects

DIAGNOSIS OF APPENDICiriS 81

out rigidity of the abdominal wall diagnosis is
usually easy, for the tender rounded gall bladder
may be felt continuous with the liver and perhaps
moving with respiration The pain in cholecystitis
IS usually a little higher than that of an ascending
appendicitis, and there may be pain of a segmental
nature referred to tlie riglit subscapuHr region,
especially if a stone be impacted in the cystic duct
Tiiere may be lesonance of the ascending colon
over an inflamed retrociecal appendix There is
never resonance m front of an inflamed gall bladder,
which IS usually on an anterior plane to the cfficum,
colon, and appendux In very stout subjects and
in patients with very rigid abdominal muscles it
may on occasion be almost impossible to diagnose
whether the appendix or gall bladder be at fault
without giving an anesthetic, unless the previous
history be clearly indicative of one or other condition
\^hen with the cholecystitis a stono is simul
taneously impacted in the cystic duct the constant
spasms of pain accompanied by retching, with deep
tenderness m the right hypochondrium and right
subscapular legion, are sufliciently diagnostic and
clearly differentiated from appendicitis
Periduodenitis round an inflamed duodenal ulcer
should be distinguishable by the characteristic
history elicited by careful questioning The pain
of duodenal ulcci comes two or three hours after
food, and is reliea ed by the taking of food

Acute nght-sided pyelitis is frequently mistaken
for appendicitis, and not infrequently operations
are unwisely undertaken because insufficient atten
tion IS paid to the symptoms The points in
differential diagnosis can be tabulated as follows
G

82 DIAGNOSIS OF THE ACUTE ABDOMEN

Acutf PyELms

Initial ngor common
Temperature 103 “ or more
Pam on micturition
Increased frequency of urmation
Abdommal muscles often lax
Pus or bacteria in urine

APPEVDicrna
Rigor unusual

Temperature so high as 103 “
uncommon

Urinary symptoms inconstant
liocal tigidvtj frequent
No pus in urme

The sjrmptoms of acute pyelitis may be produced
by the presence of bacilli in the urine without any
or much formation of pus In such cases there is
always a turbidity or opalescence of the urine it Inch
IS suggestive of the bacUluna One must not forget
also that an inflamed appendix }ying in front of the
renal pelvis may actually cause an acute pyelitis
If the unne be carefully exaimned as a routine
there zvill seldom be any difficulty in diagnosis
Acute nght*sided hydronephrosis is sometimes
misdiagnosed appendicitis with abscess formation
A hjdroneplirosis forms a rounded, tense, tender
suelling which occupies the lateral aspect of the
abdomen and can be felt well back m the loin The
swelling IS sometimes freely mo>able and usually
rounded in shape It may be possible to feel a de
pression (correspondingmth the Iiilum) on the medial
side The pain is sometimes of the type of renal colic
and there are usually urinary symptoms — scantj urine,
pain during or frequency of micturition, etc It mav
be possible to ascertain a history of pre\ lous attacks
corresponding to Dictl s crises Rigiditj ofthcabdo
minal wall over the swelling is usually absent
Acute pyonephrosis forms a similar swelling to a
hydronephrosis, but it is usually more tender, more
fixed, and the general signs of constitutional dis
turbance are much greater, eg there arcliigh feier,

DIAGNOSIS OP APPENDICITIS 83

very furred tongue, and maybe other symptoms of
toxemia There may be pus in the urine

Movable kidney without hydronephrosis — A kink-
ing of the reno ureteric junction may occur and
cause severe pain in tlie loin and diminution of
amount of urinary secretion, ivithout much swelling
of the kidney The urinary symptoms, lack of
fever, and relief of the pain when urine passes more
freely, serve to distinguish

Stone in the kidney or ureter — In those unusual
cases in which appendicitis is accompanied by pain
in the right testis it may closely simulate renal colic
An X-ray photograph should show the stone and
differentiate Cases do occur, hoi\e\er, in ivhich
small ureteric calculi do not show on an X ray
negative, and then the character of the pam must be
the deciding factor in diagnosis In one caseundermy
care acute pam in the right loin radiating to the
right testis, accompanied by fever and some muscular
rigidity, caused me to diagnose renal colic A
radiogram showed a large shadow a little external
to the normal line of the ureter Operation re
vealed a normal kidney and ureter, but a very in
flamed appendix with a large calcareous gland in
the meso appendix Fortunately such cases are rare
Torsion of omentum — ^Torsion and strangulation
of a portion of omentum maj simulate appendicitis
The part affected is usually to the right of the mid-
line, and pain and tenderness will be noted to the
right of the umbilicus If the affected fat becomes
adherent to the abdominal \^all there may be
superficial hyper'csthesia Vomiting is less com-
mon than in appendicitis, but differential diagnosis
may be impossible

84 DIAGNOSIS OF THE ACQTE ABDOMEN

Perinephric ■ abscess. —A suppurating retrocjccal
appendix may form an abscess in the neighbourhood
of the kidney, and may be difficult to diagnose from
a perinephric abscess of metastatic origin. But the
latter is insidious in origin, wiiilst appendicitis
usually gives a typically acute history of onset.
In both cases there will be pain on pressing forward
in the erector-costal angle below the last rib. Some
patients with an inflamed retrocffical appendix
present atypical symptoms, have no initial epigastric
pain, do not vomit, and present no rigidity over the
inflamed area. These cases, hoicever, are much
more rapid in development than the usual metastatic
perinephric abscess. A small retrocrecal or retro-
ileal abscess of appendicular origin may easily be
overlooked. (See Fig. 14.)

DIFFEREimAL DIAGNOSIS OF THE INFLAMED ILIAC
APPENDIX

Inflammation of the iliac appendix is the most
easy to diagnose, though there are many pitfalls.

A perforated duodenal ulcer is frequently mis-
diagnosed appendicitis. The escaping contents
travel down first to the iliac fossa and give rise to
all the signs of inflammation of the appendix. It
may be possible to obtain a typical duodenal or
appendicular history. The initial shock at onset is
greater in the duodenal condition, and there will
also be definite right hypochondriac teTidcTTi^s.
Pain felt on the top of the right shoulder would be
more in favour of a perforated duodenal ulcer. If
there be any obliteration of liver-dullness in the
absence of general abdominal distension a duodenal
(or gastric) perforation is certain.

DIAGNOSIS OF APPENDICITIS 85

Carcinoma or tuberculosis of the ileo-csecal
junction. — When a carcinoma or hyperplastic tuber-
culosis causes any obstruction at the ileo ccecal
valve appendicitis may readily be simulated There
will be recurring attacks of severe pain, vomiting,
local distension and tenderness in the right iliac
fossa, and sometimes rigidity during or after the
attack But the pam m ileo ciecal obstruction is
more griping and intense than in appendicitis,
and the vomiting comes on almost simultaneously
with the pain, and is more violent and persistent
than m any but the most advanced appendicular
peritonitis Sooner or later an attack of complete
obstruction will occur and general distension ensue
Constipation is noticed during the attacks, and loss
of weight rapidly takes place

Carcinoma of the csecum or ascending colon which
forms a tumour, and which has become adherent
to the parietes, or which has eroded the gut and
caused a perityphhtic abscess, may simulate an
abscess of appendicular origin The age of the
patient (usually over fifty), previous attacks sugges-
tive of obstruction, noticeable loss of weight and
aniemia, usually help to distinguish, but cases do
occur in which differential diagnosis is almost
impossible before operation

Ileo ccecal tuberculosis may cause symptoms
similar to those of carcinoma, and indeed may not
be distinguishable prior to operation

Tuberculous ileo-ceecal glands are easily mistaken
for an inflamed appendix They occur chiefly
in children, and cause slight tenderness, and maybe
a lump, in the right iliac fossa If the glands are
fleshy and tending to undergo caseation they may

86 DIAGNOSIS OF THE ACUTE ABDOMEN

cause inflammation of the contiguous mesentery
and peritoneum, and the local signs imII be increased
by the presence of greater local tenderness and
possibly muscular rigidity. Nausea or vomiting may
occur, but epigastric pain is not so likely to be in
evidence, and the typical symptom sequence will
not be obtained Tuberculous mesenteric glands
may be accompanied by an irregular fever An X-rav
photo may show some calcification in the glands

Psoas abscess and tuberculous htp disease may each
cause irritation of the iliopsoas with flcMon or
limitation of extension of the rJght thigh, and
tenderness, resistance, and fullness m the right iliac
fossa, but the general onset and subacute nature of
the illness, together with careful examination of
the spine and hip, m most cases easily establish the
diagnosis A radiogram should be taken if doubt
exists.

Stone in the ureter. — ^A stone passing down the
ureter causes pain, not always typical of renal colic,
referred approximately to that section of the ureter
m which the stone is lodged. Quite frequently
this causes a diagnosis of appendicitis to be made
Urinary symptoms (frequency, pain, iiicmaturia),
pain in the testicle, absence of rigidity over the
painful area, and a prcMous iastory of attacks
suggestive of renal colic, should put one on to the
right line of diagnosis , and if expert assistance be
available, radiography and cystoscopj with the
passage up the ureter of the affected side of a wax-
tipped bougie may serve to demonstrate a cilculqs
Fev er is unlikely to be present m the case of ureteral
stone

Au abscess deielopittg tn the abdominal xcall in the

DIAGNOSIS OF APPENDICITIS . 87

right iliac region may be difficult to diagnose from
appendicitis, but the history, absence of vomiting,
and superficial localization wthout any deep signs,
should differentiate.

h'S;

FiQ 14 — Diagram slioTnog those aitea where an abscess resulting from
appendicitis may someUmes be overlooked (See pages 84 and 80 )

Rupture of the lozoer segment of the right rectus
muscle may also lead to local signs similar to those
caused by appendicitis, but the history of onset
should sert’e to distinguish. Rupture of the rectus

88 DIAGNOSIS OF THE ACUTE ABDO’^IEN

IS prone to follo^\ a great or sudden muscular effort,
or may be due to a sea ere bout of coughing Vomit-
ing and intestinal sjTnptoms amII be absent

THE PELVIC APPENDIX

Differenhal diagnosis m the male — Inflammation
of an appendix situated in the pelvis gives rise to
very many mistakes in diagnosis, and in the case of
women there is some excuse for this, but in the male
there are comparatively feu conditions which cause
severe aeute pelvic pam, and mistakes should not
so frequently occur The chief are

Obstruction of the large intestine (carcinoma,
volvulus)

Obstruction of the small intestine

Diverticulitis

Stone m the lower part of the ureter

Obstruchon of the large bowel causing Iijpognstric
symptoms is commonly due to carcinoma of the
sigmoid or rectum, or to voUailus The onset of
both these conditions is usuall) preluded by a tunc
of subacute obstruction with attacks of abdominal
pain and distension, and in botli cases distension is
an early feature of the acute attack In pelv ic appendi-
citis the symptom sequence is fairly constant, and
distension is not an early symptom In botli cases
rectal examination will reveal pelvic tenderness, but
m obstruction there may be greater ballooning of
the upper part of the rectum, wlnlst in appendicitis
there is often a tender lump on the right side of tlie
pelvis, and the thigh rotation test maj be positive
In appendicitis also tliere is not complete obstnic
tion, and a turpentine enema will bring awaj flatus

DIAGNOSIS OF APPENDICITIS 89

and faecal material. Fever is usually absent in ob-
struction, and present in appendicitis.

Obstruction of the ileum, accompanied by tender-
ness in the hypogastnum, is frequently due to
adhesions caused by former attacks of appendicitis.
The adhesions usually bind the end of the ileum
dovn to the lateral wall of the pelvis or the bottom
of the pelvic pouch of peritoneum The previous
history of appendicitis may deceive Distinction
is to be made chieflj b> noting’ that in obstiuction
there is greater acuteness of pam, which is of a
spasmodic nature, and by observing the frequency
and character of the vomit, which m obstruction
gradually becomes yellowish and finally faiculent —
a cliange which never happens m appendicitis until
extensive peritonitis has developed In intestinal
obstruction the pain is seldom localized m the right
ihac fossa as in appendicitis, but after distension
has supervened diagnosis is made much more
difRcult In small bowel obstruction also the tem-
perature IS usually subnormal at onset, and does
not at any period become febrile as is usual m
appendicitis Frequency of micturition or pain
during the act may occur in appendicitis, pwing to
irritation of the bladder.

Diverticulitis of the peh ic colon may cans** either
obstructive or inflammatory symptoms. When
causing obstruction it closely resembles carcinoma,
but v\ hen local inflammation and abscess result the
symptoms and signs are very similar to those of
pelvic appendicitis, and there is no certain way of
distinguishing before operation since in these cases
a barium enema is inadvnsable. Div erticiilitis is,
however, a condition chiefly met with in older

90 DIAGNOSIS OF THE ACUTE \BD0MEN

persons, and there may be a history of pre\ious
bowel derangement which may be referable to the
colon, e g attacks of diarrhoea and constipation,
or passage of slime and blood, etc The tniital
pain IS more likely to be hypogastric m pelvic
pericolitis and epigastric in appendicitis

Perforafaon of a typhoid nicer —Wien, m a patient
suffering from a mild attack of typhoid fever, a
subacute perforation occurs in the lower ileum, a
pelvic abscess may result which may at the time
of examination be indistinguishable dimcally from
that due to a perforated appendix But the diag
nosis ivill be helped by the previous history In
one case which came under my care the patient had
been treated for two weeks for influenza before the
pelvic symptoms caused her to be sent up to hospital
for appendicitis A pelvic abscess was opened, and
a blood agglutination tesi proved that B para
typhosus fl ^as the cause of the disease

Siane xn the lower part of the ureter (see abo\ e) —
When a stone is near the bladder there arc often
additional symptoms, frequency, strangury, pam
in the penis, emissions, which maj point to the
genito urmary system Cystoscopj might shoiN
a pouting right ureteric orifice, and a catheter put
up the ureter nould stop at the site of the stone

A Pelvic Abscess following appendicitis is fre
quently overlooked especially when occupying the
right posterior quadrant of pefvis (Fig 14)

DIFFEREimAL DIAGNOSIS OP PELVIC APPENDICITIS
IN THE FEMALE

The female rcproducti\c organs add considerably
to the difiicultj in diagnosis of pelvic appcndicibf

DIAGNOSIS OF APPENDICITIS 91

Acute pain referable specially to the hypogastrium
and pelvis may be due to :

Uterine colic (dysmenorrhcea or threatening
abortion).

Twisted pedicle, inflammation, or rupture of
an ovarian cyst.

Ectopic gestation. ^

Twisted or inflamed fibroid.

Twisted hydrosalpinx.

Salpingitis or pyosalpinx.

Dysmenorrhcea, with its periodicity, lack of signs
on local examination, and pain referred to the lower
lumbar and sacral region as well as the hypogastrium,
should not cause serious difficulty in diagnosis.

In threatened abortion, the previous amenorrhoea,
bleeding, character of the pain, and absence of local
signs easily serve to distinguish.

Ectopic gestation is frequently misdiagnosed
appendicitis, but there is usually some menstrual
irregularity, often a Iiistory of a fainting attack,
general anaemia, and a displaced uterus, whilst the
symptom-sequence of appendicitis is not usually
seen. Even in unrupturcd cases the enlarged tube
may be felt as an abnormal mobile and tender
swelling to one side of the uterus. See Chapter XII.

In the case of an ovarian cyst or hydrosalpinx, with
a twisted pedicle, diagnosis is made chiefly by the
fact that with the twisted viscus the pain and vomit'
ing come on simultaneously (or almost so), so that
the proper appendix symptom-sequence is wanting;
moreover the vomiting or retching is usually more
frequent and more persistent than in appendicitis.
In the case of an ovarian cyst it may have been

92 DIAGNOSIS OF THE ACUTE ABDOjrEN

previously kno^vn that there i\as a tumour, and a
definite tender swelling may be made out from the
time of onset of the symptoms Tins sn elhng may be
situated in the mid-hypogastnum or to one or other
side, or may be limited to the pelvis Superficial
hyperassthesia to pm-stroke m the right iliac region
IS commonly found with appendicitis, but is less
frequently detected with an ovarian cyst

With a twisted fibroid the symptoms are not
usually so acute, and the presence of the fibroid ill
most likely have been knorni previously. It maj
be impossible to differentiate betueen tuistcd
fibroid atvd an ovarian cyst with twisted pedicle
Acute salpmgitis js frequently difficult to dis
tmguish from appendicitis, and sometimes the two
occur simultaneously. Occasionally it is difficult to
say in which of the contiguous organs tlie inflamma-
tion started. Distinction may usually be made by
considering the following points Acute salpingitis
does not so frequently cause epigastric pain at tlie
onset, and vomiting is less frequent. The salpingitic
pam IS frequently felt on botli sides from the
onset and there may be greater tenderness in the
left iliac region than the right. The history is
often unreliable, but the presence of a vaginal dis-
charge IS a valuable guide and examination should
be directed to this point. It has been stated that
■with salpingitis pam is more often felt donn tlic
thigh even as far as the knee, but this is certainly
not a constant symptom. If m doubt, it is better
that operation should be undertaken, but if there
IS no reasonable doubt that the condition is acute
salpingitis there are man) surgeons nlio con-
sider nonopcratiie treatment, b) putting the

DIAGNOSIS OF APPENDICITIS

93

patient into the Fowler position and giving rectal
saline injections, quite satisfactory.

A pyosalpinx may rupture and cause simulation
of a pelvic appendicitis. The typical appendicular
symptom-sequence is usually wanting. If examina-
tion be made soon after the onset of symptoms a
pelvic swelling will be felt. Tliis is usually bilateral.
A history of chronic pelvic pain and leucorrhcea
may be ascertained. In cases coming under obser-
vation after some days diagnosis may be impossible
before operation.

In late cases of appendicitis which have led to a
very diffuse or general peritonitis, or in those cases
of a very fulminating type which are associated
with a rapid form of spreading peritonitis, it is often
impossible to make a certain diagnosis. Distinc-
tion has to be made from :

Primary pneumococcal peritonitis.

Secondary general peritonitis due to other
causes {rupture of gastric, duodenal,
typhoid, stercoral, or carcinomatous
ulcer, or of a pyosalpinx).

Thrombosis of mesenteric vessels.

Acute intestinal obstruction.

Acute pancreatitis.

Pylephlebitis.

In finding out the exact cause the greatest im-
portance attaches to the historj'. Tlie subject is
considered more fully in the next chapter and in
that on peritonitis.

CHAPTER VI

PERFORATION OP A GASTRIC OR DUODENAL
ULCER

(A) Perforation into the General Peritoneal^
Cavity

Perforation of a gastric or duodenal ulcer into the
general peritoneal cavity is a catastrophe which
occurs with dramatic suddenness, and unless treated
surgically progresses in a definite manner with a
typical course until the death of the patient about
two or three days after the perforation. It is one
of the most easily diagnosed acute abdominal
conditions, provided the symptoms arc known and
appreciated, and it is the most important to diagnose
early and treat promptly by surgical intervention.
Delay in the diagnosis of appendicitis is regrettable,
but does not always cost the patient’s life, mis-
diagnosis of an inflamed gall-bladder or a pyosalpinx
is a perilous occurrence, but tlie position may
frequently be retrieved by a later operation, but in
the case of a perforated ulcer a delayed diagnosis,
or a misdiagnosis which leads to temporizing and
delay, is equivalent to a death sentence witli very
slight chance of reprieve. If operation be under-
taken inthin the first six hours recovery is the nilc, if
the opening of the abdomen be delayed for twelve
hours recovery is more doubtful, if twenty-four or
more hours elapse prior to suture of tlie ulcer and

GASTRIC OR DUODENAL ULCER 95

drainage of the abdomen the death of the patient
is to be expected. True, some cases recover though
operated on at a later stage than this, but they are
always regarded as exceptional and worthy of
comment. The very possibility of any condition
being due to a perforated ulcer is a positive indica-
tion for an immediate solution of the problem. If
the problem cannot be solved with certainty, action
should be taken for removal of the patient to the
nearest surgical centre. To leave the diagnosis in
doubt overnight will most likely cost the patient’s
life if a perforation be present.

The signs and symptoms produced by the per-
foration vary according to the time which has
elapsed since the rupture occurred. There are
three stages in tlie pathological process which can
usually be recognized easily :

(1) The stage of prostration or primary shock.

(2) The stage of reaction (with masked peri-

tonitis).

(3) The stage of (advanced) frank peritonitis

and secondary or toxic shock.

There is no hard-and-fast limit betw’een the stages,
and occasionally primary shock may lead on to
frank peritonitis and terminal collapse without any
noticeable interval of reaction.

The symptoms of each stage can be enumerated :

Stage of prostration or primary shock:

Great and generalized abdominal pain.

Anxious countenance.

Livid or ashen appearance.

Cold extremities.

Cold sweating face.

»0 DIAGNOSIS OF THE ACUTE .iHDOMEN

Stage of prostration or primary shock {continued ) :
Subnormal temperature (95^’ or 90® F.).
Pulse small and weak.

Shallo^v respiration.

Retching or vomiting.

Pain on the top of one or both shoulders.
Stage of reaction (masked peritonitis) :
Vomiting ceases.

Abdominal pain less.

Appearance much better, face regains normal
colour.

Temperature normal.

Pulse normal.

Respiration still shallow and costal in type.
Al^ nasi working slightly.

Abdominal wall verj'^ rigid, tender, and often
retracted or flat.

Tender pelvic peritoneum.

Diminution of liver-dullness.

Movable dullness in flanks.

Great pain on movement of the body.

Stage of frank peritonitis with to.vic shock :
Vomiting more frequent.

Fades that of late peritonitis.

Abdomen tender and distended.

Pulse rapid and small.

Temperature either sligiitly febrile or sub-
normal.

Abdominal wall usually not quite so rigid.
Respiration laboured and rapid.

1. Stage of primary shock . — The initial symjitoms
are those due to the pain and shock consequent on
the flooding of the peritoneal cavity with the gastric

GASTRIC OR DUODENAL ULCER 97

contents. The sudden great stimulation of the in
numerable nerve-terminations by the irritating fluid
escaping from the ruptured viscus causes reflex
depression of the vital functions This may be so
severe that the patient may feel faint or fall down m
a syncopal attack. The pulse temporarily is small
and feeble, the face livid, the extremities cold, and
the thermometer will only register about 95® T.
The face shows pain and anxiety, and the patient
may cry out in his agony

The pain is sudden m onset The patient may
be feeling well one moment, the next he is writhing
in agony and crying out for someone to relieve him.
The site of the initial pain is generally epigastric,
but quickly it extends downwards, and m a short
time IS felt all over the abdomen The pain may
even be greater m the hypogastnum, since the
escaped fluid collects in the peKis This stage may
last for but a few minutes or persist for an hour or
two. Its length depends to a certain extent
upon the size of the perforation and the degiee to
which the general peritoneal cavity is flooded In
cases where the perforation is very small and soon
sealed up by fibrinous exudate the symptoms of
onset are correspondingly less severe In some
instances of this kind the shock is almost absent and
the pulse may be regular and full when seen shortly
after the perforation.

2 Stage of reaction — ^The intensity of the initial
shock subsides, and the patient then looks better and
feels more comfortable. The circulatory system re-
covers to such an extent that the limbs may become
warmer, the face normal in colour, and the pulse
normal m frequency and strength, whilst the ther-
7

98 DIAGNOSIS or THE ACUTE ABDOMEN

mometer may show no indication eitiier of sub- ^
normality or fever. The improv ement m s\ mptoms
does not imply any stoppage of the pathological
process, though the casual observer might easily
think that real improvement were taking place
Upon the proper appreciation by the practitioner of
tins dangerous latent period depends the patient’s
chance of recovery from the disease It is in this
stage that the inexperienced house surgeon tliinks
he has made a mistake in summoning the surgeon
so urgently, and almost apologizes for having
brought him up needlessly In this stage I have
known a capable observer deluded into postponing
the summons to the surgeon since the patient was
sleeping peacefully But it is at this period that
the favourable opportunity for operation passes,
nor should there be any difiiculty in diagnosis if
careful examination be made
No certain guide is to be obtained from tlic pulse
and tempeiature, for they are frequently normal,
nor IS the patient’s own opinion of Ins condition
always to be trusted, for he often expresses himself
as feeling mucli better, and he may even begin to
think lightly of his condition But his attitude
and his acts will always belie his words Belief
will be sought by tlie drawing up of the legs, and
if he be asked to turn over m bed the attempt is
made cautiously and with evident dread of increas-
ing the pain If no morphia has been administered
there w ill still be complaint of generalized abdominal
pain, though the intensity will not be so great as at
first There are in addition five observations, some
or all of which give valuable indication of the
serious mtra abdominal mischief The abdoniiiui

GASTRIC OR DUODENAL ULCER 99

^ wall is rigid and tender, respiration shallow and of
costal type, the pelvic peritoneum is tender, and there
may be free fluid and free gas in the peritoneal cavity.

The rigidity of the abdominal wall is a constant
feature. The muscles are flat and board-like, and

even firm pressure cannot make them ^ive way.
It takes a fairly deep aniesthesia to cause them to
relax. Pressure on any part of the abdominal wall
causes pain, and may evoke retching. Tenderness
is often greater in the right iliac fossa m the case

100 DL\G\OSIS OF THE ACUTE .UBDO^ILN

'^)f a ruptured duodenal or p>Ionc ulcer The rigid
muscles do not mo\e on respiration, and the move
ment of the diaphragm is also considerablj inhibited
so that

Breathing is shalloj) and of the costal type

The tenderness of the pelvic peritoneum is a most
important sign This can be deterramed by a
rectal or, in the female, by a v agmal examination
Withm a V erv short time of a perforation the pelvis
fills with escaped contents and inflammatorv
exudate, and, though no lump can be felt, pressure
against the pelvic peritoneal pouch tlirough the rectal
wall bj the inserted finger produces pain w Inch makes
the patient wince Remember, however, that the
tenderness of the pelvic peritoneum is not alvsajs
present if the case is examined vvnthm an hour or two
of perforation and if the opemng be a small one

Movable dullness tn the flanks due to free fluid in
the peritoneal cavity should usually be determinable,
but the shifting of the patient necessary to elicit
the sign is not alwajs advisable In doubtful
cases it may be of value

The diminution or absence of liver dullness is the
sign produced by free gas in the peritoneal cavity
It IS often easilj demonstrated, but is frequentlj
ambiguous Percussion over the front of tlie liver
may produce a resonant note even wlien no free gas
IS present m the peritoneal cavity, for it mav result
from distended intestine winch is sometimes pushed
up in cases of intestinal obstruction or peritonitis
from any cause If there be no abdominal disten
Sion, however, diminution of the liv er dullness
anteriorly is significant It is alwajs of significance
to obtain resonance on percussion over the liver in

GASTRIC OR DUODENAL ULCER 101

' the mid-axillary line. If in any acute abdominaf
case distinct resonance he obtained over the liver in the
mid-axillary line about two or more inches above the
costal border j one is certainly dealing with a perforation
of a gastric or duodenal ulcer. It is only in the
minority of cases that the sign is positive.

In doubtful cases, wlienX-rays
are available, it is possible to
get great help from a simple
radiogram of the diaphragmatic
region. Bj' this means small
quantities of free gas between
the liver and diaphragm may be
observed, (See accompanying
X-ray p. 102).

An additional symptom whicli
may be helpful is the occurrence
of pain on the top of the shoulder,
either in the supra-spinous fossa,
over the acromion, or over the

clavicle, i.e. in the region of fio lo —Diagram to m-
distribution of the cutaneous » Sr.“°

branches of the fourth cervical nostio of perforation of a

, . gastric, nuoaenal, or in>

nerve. This symptom, if pre- tesimai nicer,
sent, has to be considered care-
fully with the other indications, for diapliragmatic
pleurisy causes similar pain ; but if the pain be felt
in both shoulders from the onset of the attack it is
suggestive of a perforation of the anterior wall of
the stomach causing irritation of the median por-
tion of the diaphragm. In the case of a perforation
of a pyloric or duodenal ulcer the shoulder pain is
usually felt in the right supra-spinous fossa.

3. The stage of fiank peritonitis is one that

102 DIAGNOSIS or THE ACUTE U 3 D 0 MFN

GASTRIC OR DUODENAL ULCER 103

should never be waited for, and it is regrettable
that it is still too often seen.

Locally the extensive peritonitis is clearly shown

Fia. 10 — Diagram to lUustrato th« more common abdominal causes of
acute collapse' (1) biliary colic; (2) perforated gastric ulcer; (3)
perforoted duodenal ulcer ; acute pa&creatitla ; (6) acute mtes-
tinal obstruction ; (6) ocuto perforative appendicitis. (In tbe female
ruptured ectopic gestation elioold be added.)

by increasing distension of the abdomen. Distension
of the abdomen is not a sign of a perforated ulcer —
it is an indication that peritonitis is advanced, and
that the condition has been allowed to proceed so

104 DIAGNOSIS OF THE ACUTE ABDOMEN

far that the chance of recovery is slight Yet I
hav e knowTi delay in sending up a case to hospital,
because the one who suspected perforation thought
that diagnosis could hardly be sustained in the
absence of distension

The other effects of extensive peritonitis are m
creasing and persistent vomiting, gradual increase
in rate and depreciation in force and volume of the
pulse, and the consequent decrease m tempera
ture of the extremities and bodj generally The
abdomen remains tender, but m late peritonitis the
ngiditj frequently lessens, owing to tlic toxic
effects on the neuro muscular system EuviUj, as
a result of tlie vomiting and depressed circulation,
the face becomes pinched and anMous the checks
hollow and the ejes dim and beringed with dark
circles, the so called facies Hippocratica, v\Iiich is
not so much a sign of peritonitis as the mask of
death following peritonitis

Diagnosis and differential diagnosis — During the
initial stage of shock it is nearly alwnjs possible
to say that there is a condition needing surgical
interv ention, though the exact nature of the cata
strophe maj be slightly doubtful Great Iielp is
sometimes obtained from a previous history of
chronic indigestion or of duodenal pain, coming on
about two hours after food Quite a number of
patients Iiowever, give but a recent history of
pain after food Tins is more common m the case
of young people in whom acute p>loric ulcers
appear to be not uncommon , but I hav c had to deal
with a perforated duodenal ulcer m a man of
seventj six who had never previoush had anv
svmptoms of indigestion

GASTRIC OR DUODENAL ULCER 105

If, in one who has been subject to chronic indiges-
tion, sudden collapse and very severe abdominal
pain suddenly supervene, and if at the same time
the abdominal wall becomes generally rigid, one is
justified in suspecting a perforation of an ulcer.
If in addition the pelvic peritoneum be tender, and
there be resonance over the lateral aspect of the
liver, diagnosis is certain.

In the stage of reaction the general symptoms
temporarily improve, but all the local signs remain
and become still more definite so that the careful
observer should not be misled. In the third stage,
there is no difficulty in diagnosing tliat some serious
catastrophe within the abdomen has occurred.

Differential diagnosis. — There are tliree conditions
sometimes giving rise to symptoms similar to those
of perforated ulcer, which either do not call for
operation or m which operative interference is
positively contra-indicatcd. They are :

Severe colic (either biliary or renal),
Gastric crises of tabes.

Some cases of pleuro-pneumonia.

There are five other conditions which always
call for operative treatment and which are some-
times difficult to distinguish from a perforated
gastric or duodenal ulcer. Tliey are ;

Acute panxreatitis,

Acute perforative appendicitis,
Ruptured ectopic gestation (in women),
Acute intestinal obstruction,

General or diffuse peritonitis from
OTHER causes.

106 DIAGNOSIS OF THE ACUTE ABDOMEN

Biliary and renal colic may cause severe collapse
and terrible abdominal pam. The extent of the
collapse IS not a differential point, since in biliary
colic the patient may sometimes appear in exiremis,
but diagnosis is usually clear on a consideration of
the previous history and condition of the abdominal
wall, liver dullness, and pelvic peritoneum A clear
account given of prior attacks of pam and jaundice,
or hasmaturia and the passing of gravel or a small
stone, would serve to indicate the probability of a
stone tiying to pass doun the biliary ducts or ureter
respectively

The radiation of the pam of biliary colic to the
subscapular region, and that of renal colic to the
testicle, are sufficiently diagnostic. In stone colic
the abdominal wall is not usually rigid, and the
sufferer may throw himself about or writhe in agony
while attempting to gam a more easy position
After perforation of an ulcer the general abdominal
rigidity and increase of pam on movement forbid
and prevent movement, though occasional excep-
tions occur Finally the pelvic peritoneum is not
tender nor is there any diminution of li\cr dullness
in biliary or renal colic If jaundice or hxmaturia
be observed, diagnosis will not be in doubt Renal
colic IS nearly alwajs strictly limited to one side

The gastric crises of tabes dorsalis may giv e rise to
difficulty in diagnosis, for the intensity of the
abdominal pain and tlie severity of the \omiting
may cause extreme collapse. It should be a rule
always to lest the knee-jerks and the pupillary
reactions m every acute abdominal case, for m tabes
one or other of these is nearly always abnormal.
The pitieiit, moreover, may give a history of pre-

GASTRIC OR DUODENAL ULCER 107

vious similar attacks, and on examination in a
tabetic crisis there will be no rigidity of the ab
dominal muscles, nor should there be tenderness on
examination per rectum, nor resonance over the
lateral aspect of the liver It is to be remembered
that a patient may have a perforated ulcer whilst
the subject of tabes, but in such a case some of the
last mentioned signs will be present Persisting
rigidity of the abdominal wall is never due to tabes,
and tragic misdiagnosis may occur if this point is
not remembered

Right sided or bilateral pleuro pneumonia — An
acute case of double or right sided pleuro pncu«
monn will sometimes cause considerable abdominal
rigidity, and great epigastnc pain, but m such there
are usually sufficient signs in the hmg to point to
the true cause of the condition The al'B nasi will
be w orking and the respiration rate wll be greater
than one would expect with an early peritonitis
without distension With pleuro pneumonia there
IS usually fever and a raised pulse rate Once more
rectal examination and percussion over lateral
aspect of tlie liver are of importance in diagnosis

The other five conditions are all serious states
which themselves imperatively call for an opening
of the abdomen, so that, though important, it is not
of such critical necessity to make a certain diagnosis
heSore opeMting

Acute pancreatitis simulates visceral perforation
\ery closely, and before the abdomen is opened is
generally mistaken either for that condition or for
intestinal obstruction In pancreatitis the pam is
e\cn more agonizing, but the abdominal rigidity is
not so generalized nor so constant Cjanosis and

106 DIAGNOSIS OF THE ACUTE ABDOMEN

Biliary and renal colic may cause sev ere collapse
and terrible abdominal pain The extent of the
collapse is not a differential point, since m biliary
colic the patient may sometimes appear in extreme,
but diagnosis is usually clear on a consideration of
the pre\nous history and condition of the abdominal
wall, liver dullness, and pelvic peritoneum A clear
account given of prior attacks of pain and jaundice,
or h'cmaturia and the passing of gra\el or a small
stone, would serve to indicate the probability of a
stone tiying to pass dow n the biliary ducts or ureter
lespcctn ely

The radiation of the pam of biliary colic to the
subscapular region, and that of renal colic to the
testicle, arc sufficiently diagnostic In stone colic
the abdominal wall is not usually rigid, and the
sufferer may throw himself about or nntlie m ngonv
while attempting to gam a more easy position
After perforation of an ulcer the general abdominal
ngidity and increase of pain on mo\cment forbid
and prevent movement, though occasional c\cep
tions occur Finally the pelvic peritoneum is not
tender nor is there any diminution of li\cr dullness
m biliary or renal colic If jaundice or Incmaturia
be observed, diagnosis will not be m doubt Renal
colic IS nearly always strictly limited to one side

The gasinc crises of tabes dorsalis may gii e rise to
difficulty in diagnosis, for the intensity of the
abdominal pain and the seventy of the lomiting
may cause extreme collapse It should be a rule
always to test the knee jerks and the pupillary
reactions in every acute abdominal case, for in tabtf
one or other of these is nearly always abnormal*
The pitient, morco\er, may giic a Instorv of pre

GASTRIC OR DUODENAL ULCER 107

vious similar attacks, and on examination m a
tabetic crisis there will be no rigidity of the ab-
dominal muscles, nor should there be tenderness on
examination per rectum, nor resonance over the
lateral aspect of the liver. It is to be remembered
that a patient may have a perforated ulcer ivhiJst
the subject of tabes, but in such a case some of the
last-mentioned signs ^\Ill be present. Persisting
rigidity of the abdominal nail is never due to tabes,
and tragic misdiagnosis may occur if this point is
not remembered

Right-sided or bilateral pleuro-pneiimonia —An
acute case of double or nght-sidcd pleuro pneu-
monia \vi\[ sometimes cause considerable abdominal
rigidity, and great epigastric pain, but m such there
are usually sufRcient signs m the lung to point to
the true cause of the condition. The alai nasi will
be working and the respiration-rate mil be greater
than one would expect with an early peritonitis
mthout distension With pleuro-pneumonia there
is usually fever and a raised pulse-rate. Once more
rectal examination and percussion over lateral
aspect of the liver arc of importance in diagnosis.

The other five conditions are all serious states
whicli themselves imperatively call for an opening
of the abdomen, so that, though important, it is not
of such critical necessity to make a certain diagnosis
before opersittng

Acute pancreatitis simulates visceral perforation
very closely, and before the abdomen is opened is
generally mistaken either for that condition or for
intestinal obstruction In pancreatitis the pam is
even more agonmng, but the abdominal rigidity is
not so generalized nor so constant. Cjanosis and

106 DIAGNOSIS or THE ACUTE ABD0\IEN

Biliary and renal colic may cause severe collapse
and terrible abdominal pam The extent of the
collapse is not a differential point, since in biliary
colic the patient may sometimes appear in extremis,
but diagnosis is usually clear on a consideration of
the previous history and condition of the abdominal
wall, liver dullness, and pelvic peritoneum A clear
account given of prior attacks of pain and jaundice,
or hsematuna and the passing of gravel or a smaU
stone, would serve to indicate the probabihtj of a
stone tiying to pass down the biliary ducts or ureter
respectively

The radiation of the pam of biliary colic to the
subscapular region, and that of renal colic to the
testicle, are sufficiently diagnostic In stone colic
the abdominal wall is not usually rigid, and the
sufferer may throw Jnmselt about or writhe in agony
while attempting to gain a more easy position
After perforation of an ulcer the general abdominal
rigidity and increase of pain on movement forbid
and prevent movement, though occasional cxcep
tions occur Finally the pelvic peritoneum is not
tender nor is there nny diminution of hver dullness
m biliary or renal colic If jaundice or hfcmaturia
be observed, diagnosis will not be indoubt Renal
colic IS nearly always strictly limited to one side

The gastric crises of tabes dorsalis may give rise to
difficulty in diagnosis, for the intensity of the
abdominal pam and the seventy of the vomiting
may cause extreme collapse It should be a rule
always to lest the knee jerks and the pupdl^
reactions in every acute abdominal case, for in taoo
one or other of these is nearly always abnonna
The pitient, moreover, may give a liistorv o pre

GASTRIC OR DUODENAL ULCER 107

vious similar attacks, and on examination in a
tabetic crisis there will be no rigidity of the ab-
dominal muscles, nor should there be tenderness on
examination per rectum, nor resonance over the
lateral aspect of the liver. It is to be remembered
that a patient may have a perforated ulcer whUst
the subject of tabes, but in such a case some of the
last-mentioned signs will be present. Persisting
rigidity of the abdominal wall is never due to tabes,
and tragic misdiagnosis may occur if this point is
not remembered.

Jtight-sided or bilateral pleuro-pnetimonia .^ — An
acute case of double or nght-sided pleuro-pncu-
monia nill sometimes cause considerable abdominal
rigidity, and great epigastric pain, but in such tliero
arc usually sufficient signs in the lung to point to
the true cause of the condition. The ala nasi will
be working and the respiration*rate will be greater
than one would expect ^vith an early peritonitis
wthout distension. With plcuro-pneumonia there
is usually fever and a raised pulse-rate. Once more
rectal examination and percussion over lateral
aspect of the liver arc of importance in diagnosis.

The other five conditions are all serious states
which themselves imperatively call for an opening
of the abdomen, so that, though important, it is not
of such critical necessity to make a certain diagnosis
before operating.

Acute pancreatitis simulates visceral perforation
very closely, and before the abdomen is opened is
generally mistaken either for that condition or for
intestinal obstruction. In pancreatitis the pain is
even more agonizing, but tlie abdominal rigidity is
not so generalized nor so constant. Cyanosis and

108 DIAGNOSIS OT THE ACUTE ABDOMEN

slight jaundice are more often seen in. pancreatitis,
■which usually occurs m fat subjects The diagnosis
IS further considered in the next section (p 116)

Acute appendicitis should easily be distinguished
by consideration of the history, the order of the
symptoms, and the local signs It is infrequent for
inflammation of the appendix to cause such acutel}
severe symptoms as those ushering m a gastric
perforation, but in the stage of reaction a perforated
ulcer may be, and often is, diagnosed as appendicitis
Especially is this the case with a leahing duodenal
ulcer, for the escaped contents may trickle doivn
chiefly on the right side of the abdomen and cause
pain particularly in tlie right iliac fossa Tins
simulates appendicitis closely, for the sequence-
epigastric pain, nausea and \ omiting, right iliac pain
and fever — may be produced just as m inflamma-
tion of the appendix The intensity of the initial
collapse may serve to distinguish, and the persist-
ence of tenderness over the duodenal area should
help to determine the condition In appendicitis
the abdominal rigidity is seldom so cxtensi\ c as in
perforated ulcer, and the liver dullness is normal,
though m both cases there may be rectal tenderness
In many cases of perforated duodenal ulcer, the
patient may complain of pain on the top of the right
slioulder or o\ cr the right supra spinous fossa , \ erj
rarely is shoulder pain felt m appendicitis, and uiicn
felt (due to wntatwe fluid teaching the diaphragm)
the pain ivould be more likely felt over the acromion
or clavicular region In both cases operation is
indicated

Intestinal obstruction should not gi'c rise to
difficulty save in those cases which come late for

GASTRIC OR DUODENAL ULCER 109

diagnosis. Acute strangulation of a coil of small
bowel is the most likely type to cause difficulty.
In both conditions the onset may be with acute
symptoms of collapse, pain, and vomiting and in
both there may be evidence of free fluid in the ab-
domen, but in obstruction the abdominal wall
is usually flaccid and quite unlike the rigid board-
like condition in perforated ulcer. In acute
obstruction vomiting is almost from the first a
distinctive feature, and the character of the vomit
gradually changes until it is fteculent.

In the late stages of both conditions it may be
difficult to distinguish between them, for peritonitis
is often a complication of late intestinal obstruction,
and the board-like rigidity accompanying a per-
forated ulcer tends to dimmish somewhat as the
distension increases, and as the absorption of
toxins diminishes the neuro-muscular reflex acti-
vity. In such cases the history, and possibly the
character of the vomit, may serve to differentiate.

Rupture of an ectopic gestation, leading to severe'
intra-peritoneal htemorrhage, may cause syncope
and collapse, vomiting and severe abdominal pain.
A history of menstrual irregularity may be obtained,
but one must not rely on that for diagnosis. The
main points in diagnosis are the blanching of the lips,
tongue, nails, and selerotics and the absence of true
abdominal rigidity, tliough tJie abdomen is generally
tender and tumid, especially in the low’er part. In
both cases there will be some tenderness on digital »
rectal or vaginal examination. No definite pelvic
swelling can be made out in most cases of recent
rupture of an ectopic gestation. Free fluid in the
abdomen may be detectable in both conditions,

110 DIAGNOSIS OP THE ACUTE ABDOMEN

and resonance over the front of the liver may be
obtainable sometimes with a ruptured- ectopic
gestation (due to intestine pushed up by clots of
blood), but resonance over the lateral aspect of the
liver is only obtained with a perforated ulcer.

Pain over the clavicles or in the supra-spinous
fossa is sometimes a complaint in cases of ruptured
extra-uterine gestation. This is due to diaphrag-
matic irritation by the clotted blood in the upper
abdomen.

Other forms of peritonitis can only be distinguished
from that due to a perforated ulcer by considering
the history of onset, and by determining the
presence or absence of gas on the lateral aspect
of the liver. It may be impossible to differentiate
from the results of perforation of some other part of
the gut. Peritonitis due to rupture of the gall-
bladder may be accompanied by an icteric tinge
in the conjunctiva?.

(B) RuPTanc of an Ulcer with Formation of
Localized Subpiirenic Abscess

When from one reason or another — previous
adhesions, slow leakage allowing time for deposit
of fibrin — the escaping gastric contents do not Hood
the peritoneal cavity, the symptoms are corre-
spondingly modified. TJie pain may be very great,
but the initial collapse is not so prostrating, and
the abdominal signs will soon localize themselves
to the upper segment of the abdomen and lead to
the development of a subpiirenic abscess containing
gas. If such an abscess develop anteriorly, the
local signs of intra-peritoneal suppuration arc very
evident, but when the mischief is high up under the

ACUTE PANCREATITIS 111

diaphragm the signs and symptoms take longer
to develop Irregular temperature, rigors, leuco-
cytosis, and dullness at the base of the lung
consequent on pleural effusion or basal congestion,
will lead the observer to diagnose a collection of
pus under the diaphragm A full description of
subphrenic abscess does not come ^Mthln the scope
of this book

It must be remembered that occasionally an ulcer
may perforate and allow a small leak, but the perfor-
ation may soon be sealed by a fibrin deposit Such
cases give rise to pain, rigidity and tenderness m the
right hypochondnum closely simulating the symp-
toms of acute cholecystitis, and the condition may
clear up without the formation of abscess

ACUTE PANCBEATmS

Acute pancreatitis accounts for less than 1 per
cent of the cases of acute abdominal disease and
must therefore be regarded as a comparatively rare
disease It must be exceptional for any one
surgeon to see more than two or three dozen cases
m the course of his career, so that dogmatic vieus
based on personal experience alone must be (as in
this case they arej supplemented and corrected by
careful study of the experience of others

It has been stated that the common failure to
diagnose acute pancreatitis correctly is due to neglect
to consider its possibility in the individual case, but
even when the condition is thoroughly considered
and discussed a mistaken diagnosis frequently re-
sults Probablj less than half tlie cases are correctly
diagnosed before operation A special consideration
of the symptoms is therefore all the more necessary.

112 DIAGNOSIS OF THE ACUTE ABDOMEN

To understand and remember the sjmptoins one
should recollect the anatomy of the pancreas and
the pathology of the disease The gland lies in
the retro peritoneal tissues in close relationship
with the cceliac plexus and the semilunar ganglia
The head is surrounded by and slightly o\erlaps
the curve of the duodenum , the body lies m front
of the first lumbar ertebra, whilst the tail reaches
the left loin and lies against the spleen There are
still many points in the pathology of pancreatitis
which are not settled, but there is a preponderance
of evidence to show that the acute forms of inflam
mation are almost always due to infection which
leads to severe and widespread h'cmorrhage into
the gland, with subsequent disorganization of its
substance and liberation and activation of its fer
ments If the patient li\es long enough n part or
the whole of the pancreas may become gangrenous

Acute pancreatitis seldom occurs before the age
of forty, and is more common in stout people , it
may or may not be associated with gallstones,
and the stopping up of the ampulla of Vatcr b> a
stone which may divert the bile along the pancreatic
duct is an uncommon accompaniment of tlie disease

The symptoms of acute pancreatitis are rather
variable — a fact which explains the conflicting
accounts of the disease published by indi\idual
observers The one or tw o pathognomonic
symptoms are rarely present, and the more constant
features must be carefully considered together
before a diagnosis can be determined It is better
to group the manifestations according to tlieir cause

I Symptoms due to inflaminatory tension ol tb8
gland.

ACUTE PANCREATITIS

113

1. Pain. — Though there may have been slight
attacks of pain prior to the main attack, the acute
onset is usually dramatically sudden, and fainting
may occur. The pain is excruciating and the patient
will cry out in agony. It is felt in the epigastric
zone and in one or both loins. The position of the
gland accounts for the loin-pain, and the neighbour-
hood of the cceliac plexus explains its severity.
Sometimes pain is felt in the left scapular region
and occasionally in the left supra-spinous fossa
(phrenic pain). Later on the intensity of the pain
diminishes, but it may be felt over the whole
abdomen or perhaps more in the right iliac
fossa.

2. Shock. — Profound shock usually accompanies
the pain. The cold extremities, sweating skin,
weak pulse, and subnormal temperature sufficiently
witness to the severity of the shock. The thermo-
meter may register as low as OS® F. Tlie pulse is
usually rapid and weak, but I have known it slow
and full even in the early stage of an attack, when
the other symptoms of shock were very evident.

3. Reflex vomiting or retching nearly always
occurs. Sometimes the retching is incessant, but
as a rule very little material is brought up. Tlie
vomiting is more persistent than with a perforated
ulcer. Occasionally no nausea is felt. In true
reflex vomiting the vomit is never fjcculent.

4. Local epigastric tenderness is a constant finding.

5. Epigastric rigidity is by no means constant.
It is true that soon after the onset there may be
board-like rigidity of the epigastric muscles, but
when the patient is examined there is often a lax
abdominal wall. Of sixteen cases recorded bv

8

lU DIAGNOSIS or THE ACUTE ABDOMEN

Waring and Griffith > thirteen had a soft abdominal
wall This point should be emphasized, since ex-
treme muscular rigidity was at one time thought
to be characteristic

II. Symptoms due to swelling of the pancreas.

6 Epigastric tumour. — Sometimes the pancreas may
be palpable as a transversely placed tumour in tlie
epigastrium The fact that the patients are usually
very stout and the occasional presence of rigidity
often make the detection of the tumour difficult

7 Jaundice. — Slight jaundice is found in about
half the cases Since frequently, if not usuallj , there
are no obstructing’ grail stones, the most reasonable
explanation for the jaundice is that the common
duct is compressed by the swollen head of the pan-
creas The common duct is normally surrounded
by the head of tlie gland in two out of three cases

8. Obstructive vomiting. — True obstructiNC
vomiting of great amounts of fajculent or bilious
matenal is very rare, but I have personal knowledge
of one such case At the operation the swollen
pancreatic head was de/initcJy obstructing tlie
duodenum This type of vomit must be dis
tinguished from the more common reflex vomiting
mentioned above

III Symptoms due to extravasation of blood.

9 Ecchymosis of one or both loms is an occasional
symptom The extravasated blood finds its wa>
along the retro peritoneal tissue planes and becomes
evident as a greenish yellow or purplish stain in
the loin external to the erector spimj muscle mass.

> See Dnlish Journal of Surgery •vol xi, p -ITO Wc wWi to
express our indebtedness to this arUcle. wldcli wc constder the imwl
valuable jet written on the subject

ACUTE PANCREATITIS 115

This symptom can only appear after tAvo or three
days from the onset of the disease When present
it IS absolutely pathognomonic

IV Symptoms due to deranged gland function.

10 Glycosuria is oecasionally found, and m any
case of acute abdominal pain should raise the
question of pancreatic disease

11 Increase in the urinary diastase — The libera-
tion of the pancreatic ferments leads to an increase
in the amount of diastase in the urine Normally
the urine contains about 10 to 20 units of diastase,
but in acute pancreatitis this may be increased to
100 or 200 units Facilities for tins test are, how-
ever, not always handy

V Other symptoms.

12 Cyanosis — Tins symptom has been noted in
a considerable number of cases It is best observed
in the face and extremities, but lias sometimes been
present in the skm of the abdomen

13 Djspncea is occasionally noticeable It is
reasonable to suppose that a partial inhibition of
the diaphragmatic movements, ov\ing to the con-
tiguous inflammation, may account at any rate in
part for the cyanosis and dyspnoea

14 Loewe’s test or idrenalm mydriasis is some
times positive A drop or tv\o of a 1 m 1,000
adrenalin hydrochloride solution is dropped into
one conjunctival sac and the procedure repeated m
five minutes Within half an hour the pupil on
the tested side only should dilate if the test is
positiv e Tlic test indicates disturbance of the
suprarenals by contiguous disease, and is found
occasionally in acute pancreatitis

It should be remembered that in the later stages

116 DIAGNOSIS OF THE ACUTE ABDOSIEN

of acute pancreatitis a more general abclomnial
condition results , blood-stained fluid collects in
the peritoneal cavity, distension supervenes, and
there may be irregular fever It is -very difficult
to diagnose such cases without a \ery accurate
previous Jiistory of tlie case

Diagnosis. — ^Acute pancreatitis is most commonlj
mistaken for a perforated gastric or duodenal ulcer.
The less acute cases may be misdiagnosed appen-
dicitiSy ^\hilst those cases with distension may
easily be regarded as examples of intestinal
obstruction Acute cholecystitis and biliary colic may
also simulate the symptoms of pancreatitis.

With a perforated ulcer general abdominal rigidity
is constant in the early stages after perforation,
whilst in pancreatitis the abdomen may be softer,
and any rigidity is usually limited to the epigastric
zone In his original paper, Fitz \ery accurately
wrote that the symptoms of acute pancreatitis 'Nscre
those of an epigastric peritonitis In a case of
perforated ulcer the symptoms are usually more
widespread Pain on top of the shoulder is fre-
quently felt \\hen an ulcer perforates, ^vith pan-
creatitis such pam is rare, and is felt on top of the
left shoulder Bilateral lumbar pain, cyanosis, and
slight jaundice ^^ould be in fa\our of pancreatitis,
whilst absence of livcr-dulIncss in the nxilhry line
would definitely indicate perforated ulcer Glyco-
suria, a positi\e Loewc test, or (when the test can
be made) a great increase in the diastase content
of the urine would point to pancreatitis

Appendicitis is generally distinguishable if careful
attention be paid to the liistory of onset and the
order ot symptoms The ^omltl^g and pam are

ACUTE PANCREATITIS

117

both less severe in appendicitis, and there may be
definite local symptoms in the right iliac fossa
With acute cholecystitis and biliary colic tenderness
IS felt more in the right hypochondnum, and there
may be a definite history of previous attacks, whilst
hyperiesthesia to pin-strokc in the superficial dis-
tribution of the 8th or 9th thoracic nerves may
point to gall-bladder trouble. The tests of
glandular derangement may help to determine,
but it must be remembered that cholecystitis and
pancreatitis may co-exist.

When distension has supervened it is difficult
to (irstmgufsh frour Che fade stages of peritonitis
and intestinal obstruction unless positive tests of
deranged gland-function and a very clear history
point to the correct diagnosis

With every care m investigation ac-ute pancreatitis
IS frequently only diagnosed with certainty when
the abdomen is opened and blood-stained fluid and
areas of fat-necrosis seen.

CHAPTER VII

ACUTE INTESTINAL OBSTRUCTION

Acuti. obstruction of the intestine in the form
of strangulated liernia was one of the fust of the
abdominal emergencies to be leferie^ to tlie surgeon
for treatment, whilst obstruction accompanied bj
«'imilar symptoms, but due to internal causes which
were not so obvious as an external hernial swelling,
was amongst the latest of the urgent abdominal
cases to be given up by the physician to the surgeon
Medical treatment was, until comparativclj re*
cently, recommended to be tried ns a first resort,
and only when a course of treatment b) aperients
and enemata failed to relieve vas tlic operating
colleague called m to see the patient If tliere be
any condition m whicli early diagnosis and operative
treatment, and avoidance of attempts at purgation,
are necessary, it is intestinal obstruction. For
a patient to be allowed to continue in \iolent pain,
and to vomit repeatedly whilst the abdomen
gradually becomes distended, is unfair not only to
the patient but also to the surgeon w ho maj ln\ c to
operate m conditions made so much worse by delay.

The pathology and causation of acute intestinal
obstruction are far too big questions to discuss fully
in a small book We are lierc concerned only with
the common causes and tlic mam types of cases

ACUTE INTESTINAL OBSTRUCTION 119

which come for diagnosis. It is not always essential
in diagnosis to know the exact cause of the obstruc-
tion, though every effort should be made to ascer-
tain it as accurately as possible. It is useful to
have a knowledge of the proportion of cases due to
the mam pathological causes of obstruction. In
a consecutive senes of 301 cases of intestinal ob
struction at St. Mary’s Hospital, 177 were due to
strangulated heinia and 124 to all other causes
combined It is a mistake to treat strangulated
external hernia in a different category from
obstruction in which no external cause is to be
found. Strangulated liernia is the most common
form of intestinal obstruction, and is responsible
for many more deaths than any other single cause
of that condition (see Chapter I). Apart from
strangulated external hernia there are only three
common forms of intestinal obstruction — intussus-
ception, carcinoma of the large bowel, and obstruc-
tion by adhesions or bands. Volvulus, gall-stone
obstruction, fibrous and tuberculous stricture of
the gut and all the rarer causes are responsible
for only about 15 per cent of the cases The
very rough generalization may be made that in
infancy acute obstructive symptoms arc usually
due to intussusception ; in childhood, adolescence,
and early middle age to bands and adhesions ;
and JUD Jflter life to cancerous stricture of the
large bowel. Adhesions or bands attaclicd to
the region around a formerly inflamed appendix
are responsible for many cases, whilst a Meckel’s
diverticulum is in younger life responsible for some
band-obstructions.

When the bowel is obstructed so that nothing con

120 DIAGNOSIS OF THE ACUTE ABDOMEN

pass the obstruction the course of the disease is
inevitably toi^ards a fatal issue unless the obstruc-
tion be relieved either by .

(a) The spontaneous rectification of the condition
— which is almost unknoivn save in a fev cases of
reduction of an obstructed hernia, and the oc-
casional cure of an intussusception by the slough-
ing of the invaginated part ,

(b) Formation of an external fsecal fistula ; or,

(c) Operative interference.

The third method is in all cases desirable Until
comparatively recently the mortality after opera-
tion in cases of intestinal obstruction (excluding
strangulated exteinal herniic) nas veil over 50 per
cent , and e\ en non it is more than it should be
because the patients are not operated upon carl}
enough. The main desideratum is to diagnose
the cases early There are fev cases of intestinal
obstruction vhich could not be remedied or allevi-
ated if brought to the surgeon vithm tvehe hours
of the onset of symptoms

Intestinal obstruction may exist in a clironic or
subacute form for a considerable period before a
really acute attack ensues In the chronic form
the symptoms are similar in kind but different in
degree from those resulting from an acute attack
Chronic obstruction sooner or later terminates in an
acute attack

The symptoms of acute intestinal obstruction
differ greatlj according to the site of obstruction
The Iiigher up in the gut is the stoppage, the more
severe are the symptoms It is usual!} possible to
say approximate!} i\ hat part of the gut is obstructed,
and cases ma} be di\ ided roughh into three classes

ACUTE INTESTINAL OBSTRUCTION 121

— those due to obstruction of (1) upper small gut,
(2) lo^^er small gut, (3) large bowel, respectively
General symptoms of acute intestinal obstruction :

Pam

Shock

Vomiting

Constipation (inability to pass faeces or flatus)
Distension

Tenderness of abdomen
Visible peristalsis

Pam IS usually very severe from the onset It is
referred to tlie epigastric and umbilical regions, or
even sometimes to the hypogastnum, and frequently
comes on in bouts oi spasms, though if a consider
able segment of mesentery is implicated the pain
may be continuous The spasmodic pam is due
to the peristalsis of the intestine trying to overcome
the obstruction This can easily be demonstrated
during the examination of an intussusception, when
the soft tumour may be felt to harden just before
the screaming of the infant The initial pam is
similar to that caused by any severe stimulation of
the abdominal sympathetic, and is often accom-
panied bv those symptoms consequent on such
stimulation and comprised under tlie term “ shock ”
Primary shock or collapse — In severe cases the
puis^ may he the akin cold and sweating, the

temperature subnormal, and the pupils dilated, but
as a rule tlie symptoms are not so severe as this,
and in most cases of severe primary shock a reaction
follow s, and the patient though still m pam appears
and feels a little better

Vonutitig IS an almost constant fcatme, but 'n aries

122 DIAGNOSIS OF THE ACUTE VBDOMEN*

verj' greatly in the different forms Tiie higher up
in the intestine the obstruction, the sooner \ omiting
sets in and the more violent is the regurgitation
In obstruction of the large boi\el vomiting mav be
absent but nausea is constant. In obstructive
vomiting, first the stomach contents are expelled,
then green bilious material appears, and, if tlie
obstruction be some waj down tlie small intestine,
the vomit graduallj changes to yellow or greenish
brown and becomes fteculent A fscculent vomit,
in the absence of peritonitis, is diagnostic of intes-
tinal obstruction, though it should be regarded as
a late sjmptom of that condition Tiic nature of
the vomit is therefore to be watched ver)’ care-
fullj, and the vomited material sliould never be
thrown away till seen by the medical attendant
True fsccal vomit is only seen wlicn a communica*
tion exists between the colon and stomach

Constipation is one of the symptoms of intes-
tinal obstruction, but it is not alwajs evident at
first If the bowel be occluded at anj spot, it is
clear that no contents can pass the occluded area,
but the gut below the stoppage can empty itself,
so that for a time the bowels maj be opened. So
soon as the lower bowel is emptied (either naturally
or by enemata) neither flatus nor freces pass In
doubtful or subacute cases the plan of giving two
turpentine enemata with an interval of a few hours
/tW iy’ JXarowxd/ .w gvond Tlxn Urst

empties the lower bowel, and the second proves or
disprov cs the existence of obstruction But it is
conceivable that both enemata might bring a return
of faical matcrnl and jet obstruction exist. In
very acute cases the shock is so great that the gut

ACUTE INTESTINAL OBSTKUCTION 123

may be too paralysed to allow any natural move-
ment of the bowels, though an enema may evacuate
fcecal contents. There are many acute cases in
which constipation siiould be regarded as a sequel
rather than a symptom, for valuable time may

Fia. 20 — Drawing to show ladder pattern ot abdoimnat distension (indi.
eating obstruction of the lower ileura).

be lost in the attempt eitbet to open the bowels
or prove that the obstruction exists. If the other
symptoms of intestinal obstruction are 2 ^^csent it is
unwise to xvait Ucelve or twenty-four hours to demon-
strate constipation. It is advisable to point out
that in acute intussusception there is occasionally
incomplete obstruction, so that some brown or

124 DIAGNOSIS OF THE ACUIE ABDOMEN

yellowish faecal material may come awa} m
addition to the blood and mucus

Bistermon is usually late m appearing in the
acute cases, or m those in iihich the upper part of
the small intestine is affected But ahvajs sooner
or later it is m evidence In obstruction of the large
bowel and loiicr end of the small bond it ma} be
apparent by the time the sjmptoms become acute
enough to call the serious attention of the patient
It IS indeed because of the slightness of tl»e symp
toms — pain and vomiting — that the distension is
allowed to proceed so far

Distension at first maj be merely local, owing to
the dilatation of the coils of gut immediately aboi c
the obstruction In some cases where ordinnr)
clinical examination docs not show anN definite
distension an X raj photo mn> reveal local dis*
tension of the intestine In obstruction of tlic end
of the ileum a local hv'pogastric distension nm\ first
be obsen ed, and m \ oKtjIus of the sigmoid tlie out
line of the affected coil of large bow cl maj stand out
very distinctly In subacute or partial obstruction
of the lower end of the small bowel the distension
graduallj dilates to a moderate degree coil after
coil, so that when the patient comes under obser-
vation with acute symptoms tlic t}pical ladder
pattern tjpe of distension is seen on looking at the
abdomen (Fig 20 )

Tenderness of the abdomen is not usuall) seen till
distension appears Pressure over a distended coil
IS generally painful In the later stages of obstruc-
tion when peritonitis has ensued there may be
general pam all over the abdomen linndity of the
abdominal wall is unusual sivc m those c iscs where

ACUTE INTESTINAL OBSTRUCTION 125

there is some local peritonitis round the obstructed
area

Visible peristalsis is not a constant accompani
ment of obstruction, but is diagnostic when present,
except in some few very thm persons m whom the
normal peristaltic movements of the intestines
can easily be seen through, the abdominal wall
It IS not usually seen in the very acute cases of
strangulation, but in subacute obstruction it is more
frequently noted and is very valuable in diagnosis
In some instances peristalsis may be accompanied
by a gurgling of gas which may occasionally be
heard to pass through a narrowed part of the gut

Types of obstruction. — ^The features of an attack
of obstruction vary accoiding to (1) the part of
gut obstructed, (2) the completeness or otlienvise
of the stoppage, and (8) whether the mesentery
\Mth the contained blood vessels is also affected.

(1) The symptoms due to obstruction — (a) high
up in the small intestine , (b) low down in the small
intestine , and (c) m the large bowel — can be
roughly differentiated

(a) Obstruction high up in the small gut leads to
acute symptoms, vomiting comes on very early and
is frequent and violent, initial shock and pain arc
greater, and distension is not an early feature The
vomit IS green and bihous Sucli symptoms are
typically seen nhen a Jorge gaJJ stone ulcerates into
the duodenum (a rare occurrence). Obstruction of
the duodenum bj a cicatrized ulcer may sometimes
be acute owing to sudden spasm and oedema round
the ulcer In such cases c\erj thing taken b>
mouth is returned, but no ftcculent ^omlt occurs
and sometimes peristalsis of the stomach may be

12G DIAGNOSIS OF THE ACUTE ADDOMEN

seen. Distension is only seen in the epigastric
region.

(b) In obstruction of the lower part of the small
intestine the symptoms are less severe than tliose
just summarized. Shock and pain may be great,

1 10 11. — Dingram to sliotr appearance of moJeroto diatonsion of tbo
largo gut.

bnt vomiting iS nsnaUy a Uttle later in oivsct ; and
some time elapses before fajculent vomit occurs.
Distension comes on after a few Iiours. In subacute
cases the ladder pattern of distension is seen, and
peristalsis is often visible.

(c) In large-bowel obstruction pain is niucli less

ACUTE INTESTINAL OBSTRUCTION 127

acute, shock is comparatively insignificant (except
m some cases of volvulus and intussusception),
vomiting is a fairly late and infrequent symptom,
whilst distension from tlie onset of the acute attack
IS the rule An exception must be made in the
case of intussusception, for in these cases distension
IS not an early symptom and should not be waited
for, since a distended abdomen accompanying an
intussusception generally means that the chance
of recovery is slight.

(2) and (3) It is possible to distinguish two
mam groups of cases — differing greatly in pathology
and symptoms. Tlie first group comprises those
cases m which tlie obstruction is complete and
accompanied by a strangulation of the mesentery
of the gut. Obstruction by bands, external or
internal hernia, or lohmlus may lead to this. TJie
onset IS usually \ery sudden, accompanied by
collapse or severe shock, great pam and earl>
vomiting. If the gut is completely ivitlim the
abdomen peritonitis may ensue rapidly and bj the
time the ease comes to the surgeon there maj be
considerable abdominal iigidity on this account

The second group, in which the mesentery is not
affected, includes those cases where the obstruction
IS rather more gradual, and commonly due to a
kinking of the gut consequent on adhesions between
the bowel and either a calcified gland, the abdominal
wall, or anotlier viscus or tumour. In these cases
the onset is more insidious, the pam is not so se\ ere
and may have intervals of intermission, the vomit-
mg may for a day or two be slight m degree, and
distension comes on but gradually. Quite com-
monly such cases do not come to the surgeon until

128 DIAGNOSIS OF THE ACU'lE ABDOMEN

fasculent vomit has appeared In these cases the
abdominal vail is quite flaccid, since peritonitis is
absent, for the gut remains intact, and its blood-
supply in the mesentery is unimpaired This tjpe
is the variety which may occur after abdominal
operations, when a certain amount of pain, vomit-
ing and distension is usually to be expected There
IS therefore all the greater need to natch such cases
carefully

In the gradual narrowing of the gut lumen due to
stricture, subacute volvulus, or chronic mtussusctp
tion, and m cases where only a part of the lumen
of the bowel is nipped in a hernial aperture (Richter’s
hernia), the onset of symptoms is still more gradual,
vomiting IS less, and the pam is intermittent

We would like to point out that a Richter’s
hernia of the CTcum (of which one instance has
occurred in the author’s practice) may bo unaccom-
panied by any' obstruction of the bowel and the
herniated part of the gut wall may become gan
grenous without giving rise to any acute sy mptoms

When omentum only is strangulated there arc
subacute symptoms of obstruction, pain, vomiting,
and some distension, but the vomiting never be-
comes fiecuicnt, and the obstruction is never com-
plete — for flatus and fpcccs arc brought away by
enemata The general symptoms in onitntal
strangulation are usually slight, but if a large mass
becomes gangrenous (c g in an umbilical hernia)
serious symptoms and even death may result.

Diagnosis of small-gut obstruction — Mhen a
patient is seized with acute abdominal pain,
becomes collapsed with feeble pulse, cold extremi-
ties, anxious look and sweating skin, and soon

ACUTE INTESTINAL OBSTRUCTION 129

begins to vomit first tJie stomach contents, then
bile, then yellowish material which becomes
brownish and fseculent smelling, while the abdomen
remains flaccid, flat, and not tender, that patient
IS suffering from acute obstruction of the small
intestine The diagnosis should be made ivithout
waiting for distension to appear, nor — if the above
symptoms are present — ^is there any need to demon-
strate constipation If the symptoms are not so
acute there will be additional signs, for there is an
inverse proportion between the acuteness of the
symptoms and the probability of the presence of
signs When pain and vomiting and shock are
slight, distension and visible peristalsis are more
hkelj to be seen and constipation, tested by two tur
pentine enemata, can usually be demonstrated
definitely

Diflerential diagnosis o! acnte obstruction of the
small intestine. — Diagnosis must be considered
either before distension has developed or after that
symptom has appeared In any case, alnays
examine Jirst all the kemtal orifices

Whln no distension is present acute obstrue
tion lias to be distinguished from all the other
acute abdominal catastrophes From the acute in-
flammations — perforated gastric ulcer, pancreatitis,
appendicitis with peritonitis, ciiolecystitis — it is
distinguished by the absence of rigidity and by
the more ircquent vomiting' tv/hoA tends to become
fmculent Renal and biliary colic are distinguished
by the location and radiation of the pam and the
absence of fajculent vomit Neither stoppage of
the bowel contents nor distension follows tlie colics
In torsion of a \iscus (o\arian cyst, testicle) the
9

130 DIAGNOSIS OF THE ACUTE ■VRDOMEN

vomiting does not become fisculent Gastric crisis
IS excluded by finding no other sign of tabes. It
IS usually sufficient to test the knee jerks and the
pupillary reactions

When distension is present one must consider
the question of urzemia, mesenteric thrombosis or
embolism, or the late stage of peritonitis due to anj
cause In many cases in which the diagnosis of
obstruction of the small intestine is m question
help may be obtained from a plain X ra) of the
abdomen , this may show localized distension or
coils containing fluid le\els

Urcemia should be diagnosed by careful con-
sideration of the history, by examination of the
urine for albumin, and maybe by delecting enlarge-
ment of the kidneys Sometimes m uriemic patients
there may be a mere trace of albumin m tlic urine,
but a low specific gravity would make one suspicious,
and examination of the heart and determination of
the blood pressure may throw liglit on the case

Acute blockage ol the mesenteric arteries or \cins
by an embolus or thrombus may lead to symp-
toms indistinguisliable from those due to internal
strangulation In both cases the vascular dis-
turbance leads rapidly to serious clinngcs in the
bowel With primary mcscntcnc thrombosis the
extent of gut affected is likely to be greater, and
distension of the abdomen appears more rapidly.
Sometimes a palpable mass is formed by the affec-
ted coil or gut A history of recent endocarditis
might point to a possible embolism, whilst hepatic
disease or previous thrombotic trouble would some-
times suggest the possibility of mesenteric throm-
bosis Though there is no mechanical obstruction

ACUTE INTESTINAL OBSTRUCTION 131

m the intestines in a case of vascular occlusion,
the aiEfected gut soon becomes paralysed, never
theless the blood which is almost always poured
into the bowel lumen as a consequence of the in-
farction sometimes passes into the gut farther on
and can be demonstrated by the administration of
an enema (Cokkinis)

Unless promptly dealt with, mesenteric thrombosis
IS soon followed by peritonitis

It may be impossible to distinguish between a late
case of intestinal obstruction and late peritonitis,
unless the history give some indication In late
peritonitis there is usually paralytic intestinal
obstruction, whilst in the late stages of mechanical
obstruction there is frequently peritonitis In peri-
tonitis, however, the vomit is seldom so definitely
fseculent as m late mcchamcal obstruction
Obstraction of the small intestine by a gaU>stone
can sometimes be distinguished by certain features
first described by Barnard

A gall stone which causes obstruction generally
ulcerates into the duodenum, causing the symptoms
of very acute obstruction, i c severe pam and
frequent \omitmg of e\crything taken into the
stomach Tlie ^ omitmg may contain blood from
the ulcerated opening and this maj lead to an
erroneous diagnosis of gastric ulcer The stone passes
on gradually and the symptoms abate considerably,
but in a day or two it stops again at the lov er end
of the ileum (which is the narrowest part of the
small intestine) and the symptoms recur Tliere-
fore if one is faced with a case showing symptoms
of obstruction of the upper sinall-gut in ^\hlch these
symptoms subside but are followed m a day or two

132 DIAGNOSIS OF THE ACUTE -VBDOMEN

by those suggestive of obstruction of the lower
small-gut, the cause is likely to be a gall-stone.
This is the more likely if there has been a history
suggestive of gall-stones oT if the patient is a fat
woman of middle or advanced age. Occlusion of
the small intestine by a gall-stone is the oiilj’ type of
obstruction m which I have seen faiculent vomiting
come on very early and persist (with diminishing
frequency) without any serious collapse or abdom-
inal distension superv'ening. Wiat little distension
develops may be concealed by a fat abdominal w'all
so that the abdomen may actually appear normal.
The character of the vomit remains frcculcnt though
there may be longer intervals between the bouts
of pain and vomiting. Considerable distension may
develop towards the end of the case. The above
characters make gall-stone obstruction of the small
intestine more easy to diagnose than would be con-
sidered likely from the rarity of the condition.

Diagnosis of obstruction of the large gut.— Obstruc-
tion of the large bow'el is commonly due to one
of three conditions — stricture, intussusception, or
volvulus. The stricture is usually of a cancerous
nature, but may result more raxely from diverticu-
litis or pressure of fibrous tissue external to the gut.
Each of these three conditions must be considered
separately. We shall not consider separately tliose
cases of obstruction of the large gut by pelvic
tumours, since the primary condition is usually
evident.

CHAPTER VIH
INTUSSUSCEPTION

Intussusception or invagination of the intestine
js the most common abdominal emergency in child-
ren under tA\o years It is much less common in
later childhood and adult life, only 30 per cent of
cases occurring after the second year of life The
catastrophe is all the more unexpected m that it
usually attacks the most hcalthv looking and well
nourished babies Tlie condition consists in the
invagination of one portion of intestine into the
portion next to it Commonly, if not invariably,
the invagmated part (mtussusceptum) enters the
part below (intussuscipiens) Clearly the most
anatomically favourable part for such an occurrence
is in the ileo cxcal region, where the narrow ileum
can readily enter the lax ccccum, and m actual
clinical experience this is the most common place
tor the condition to start (Fig 22) There are three
varieties of intussusception — enteric, entero colic,
and colic Enteric, where tlie small intestine alone
IS involved, is uncommon , colic, in which the colon
alone is affected, is less rare but not very common ,
entero cohe is the most common variety. The
entero colic type is subdivided into ileo crocal, m
which the apex of the invagmated part is the ileo-
cecal valve, and ileo colic, in which a part of the

133

134 DIAGNOSIS OF THE ACUTE ABDOMEN

gut near the end of the ileum forms the advancing
apex.

In the case of the most common form — the entero-
coUc — as the end of the ileum is invaginated into
the colon a portion of the mesentery goes u’lth it

Fio 22 — Types of intuMusception (1) ileocK«al, (2) enteric (nlJch
u termed ileo colic ” if it progress beyond the iIeo-c«caI rstve) >
(3) colic

and constriction, and later strangulation, of tlie
vessels occur, causing oedema of tlie gut-uall with
intestinal Iiaimorrhage and finally gangrene. The
irritation caused by the intruded gut leads to an
excessive secretion of mucus Tlie part of the gut
uiiich first becomes m\aginatcd rciiiains at tlic ajxix

INTUSSUSCEPTION 135

of the advancing portion, and it progresses at the
expense of the ensheathmg layer (intussuscipiens)
The apex is sometimes extruded at the anus If left
untreated intussusception ends in one of two ways
Most commonly the intestinal lumen is gradually
occluded, and acute intestinal obstruction and
death from toxsemia or peritonitis result , or more
rarely the invagmated part becomes completely
gangrenous, and passes per anum as a large slough
In pre operative days many such cases i\ere re
corded, but, since it was a comparative rarity for
infants to recover from the condition, such a
fortunate event as a natural cure by gangrene of the
intussuscepted part was usually recorded

The cause of intussusception appears to be the
presence in the gut of something which provokes
excessive peristalsis It commonly occurs in infants
at the iseaning time, ivhen there arc likely to be
occasional portions of undigestible solid food taken
by the well nourished baby In later life tumours of
the gut all are commonly the cause of the condition
The symptoms of intussusception are usually
characteristic They comprise a few or many of
the following according to the stage at which the
case IS seen

(1) Abdominal pain

(2) Shock

(3) Passage of blood and mucus per anum

(4) Vomiting

(5) An abdominal sivclimg

(0) Visible peristalsis •

(7) Constipation

(8) Absence of cxcum from the right iliac

fossa

136 DIAGNOSIS OF THE ACUTE ABDOMEN

(9) Tenesmus

(10) Distension of abdomen

(11) Appearance of apex of intussusception

at anus

(12) Peritonitis

(1) The onset is usually wth a f\t of screaiiiing—
the infant’s method of indicating pam Tiie legs
are draiin up during the screaming attacks The
pain is very se^ere, but is not continuous, and
corresponds to the violent peristaltic contraction
of the gut Between the bouts of pam the child
may lie quiet, but often has an apprehensive look
Very rarely the child does not scream or siiow any ,
sign of abdominal pam other than pallor and
drawing up of the legs

(2) The seventy of the pain is shoi\n b} the sl/mp
toms of shock which accompany it The extreme
facial pallor, the dilated pupils, and anxious appear*
ance of the child are sulTiciently demonstrate e

(3) At a period varying according to the site of
the invagination — later if it starts in the ileum,
earlier if in the transverse colon — blood and mucus
are -passed per anum Tins usually occurs within
a few hours The blood is often quite slight in
amount, and it is seldom copious Slimy mucus is
mixed with the blood, and not infrequently some
brown or yellow ficcal material may also be passed

(4) Vomxling generally occurs, but it is not sc^crc
at first It is never a serious feature until the
late stages when obstruction has ensued or pen
tomtis developed The contents of the stomach
are returned, any liquid taken is not retained by
the viseus, and later there niaj be bilious ^ omit,
but fwculeht \ omit is rare

INTUSSUSCEimON

137

(5) By the time blood appears per anum a tumour
will be present in the abdomen It is caused
by the invaginated gut, and is felt either m the
right loin, right hypoehondrmm, epigastrium, left

Fio S3 — Diagrani to show possiblo positions of abdominal tumour in
coses of uxtussusceptiOD.

hypochondrium, left lumbar region or left iliac
region, according to the advance made bj the
intussusception through the colon The tumour is
oval in shape, and has often been compared — quite
aptly — to a sausage Sometimes the swelling

138 DIAGNOSIS OF THE ACUTE ABDOMEN

becomes harder, the change corresponding to the
muscular peristaltic contraction. Frequently it is
easy to feel the swelling, but in many cases an
anaesthetic is necessary to relax the abdominal wall,

m dialkngiusbing bom eobtis.)

and o^’en wlien the cliild is anrcstlictized it may be
dilficult to identify an intussusception which lies
under cover of the liver. The hiding of the inlussus^
ceplion hy the overhanging liver is responsible for
many failures to detect the iumour.

INTUSSUSCEPTION 189

(6) Peristalsis may sometimes be seen through
the abdominal wall, and the simultaneous hardening
of the tumour has been referred to above.

(7) In the common entero-coHc variety almost
from the beginning of the illness the right iliac fossa
xvill appear empty on palpation, owing to the taking
up of the CEEcum into the advancing invagination
(Signe de Dance).

(8) Constipation is by no means always absolute.
Exceptionally an intussusception may be present
and yet the bowels may open fairly normally, and
not uncommonly fa:cal material may be mingled
with the blood and mucus which come away. As
the condition advances, however, the obstruction
increases, and ultimately becomes absolute. One
must therefore be prepared sometimes to diagnose
intussusception in the absence of absolute constipa-
tion.

(9) As the intussusception approaches the rectum
tenesmus may be indicated by the constant strain-
ing efforts of the infant. At this stage the congested
apex may sometimes be felt on rectal examination.

(10) In late or neglected cases the increasing
obstruction of the lumen of the gut results in
abdominal distension and increased frequency of
vomiting.

(11) In some cases the apex of the intussusception
may protrude through the anus as a red congested
fleshy mass.

(12) The final stage is that of complete intestinal
obstruction, and peritonitis due to gangrene of the
devitalized gut and infection of the peritoneum.
Repeated vomiting, signs of toxicmia, and exlmus-
■ tion end the scene.

140 DIAGNOSIS OF THE ACUTE ABDOMEN

Diagnosis. — ^It is not usually difficult to diagnose
an intussusception The age of the child, the
previous good health and sudden onset of acute
pain coming on m bouts, which cause se\ere tem-
porary shock, the passage of blood and mucus per
rectum, and the presence of a sausage shaped
swelling in the abdomen are sufficiently character-
istic to admit of no doubt The cases of real doubt
are those in nhieh nhen the doctor secs the patient
the attacks of pain may be quiescent and no
tumour can be felt In such cases, if the history
is at all suggesti\ e or characteristic, and blood and
mucus ha\e been passed, an aiiTsthctic ma> be
gi\en m order to examine the abdomen tarcfully
for a lump If an X-raj apparatus is available
it IS better to give a banum enema and take photo-
graphs By tins means the diagnosis can l>e de-
finite!} made, and at the same time the cnenm will
help to reduce an} intussusception which maj be
present (See Fig 25 )

Differential diagnosis. — In the early stages the
condition must be distinguished from •

Simple colic
Colitis

Rectal polypus

In the later stages one must exclude
Prolapsed anus

Other causes of obstruction and peritonitis
Henoch’s purpura

^Ylth simple cohe the evidence of pain is not so
outstanding, nor is shock so extreme Xo lump
can be felt m the abdomen, and no blood is passeil

(“)

Flo. 25. — Series ofradiogTftms taken during tho administration ofa barium
enoma in a case of intussnscoption.

(a) Tlie opaque barium stopi>editaadvaoco in tlio transverse colon
at the site of the intussu.’ieeption.

(t) Tbo enema is rcdocing tho intu<MU3ccption and filling the
ascending colon.

(c) Tlio intussusception has boon forced back to tho c®cum which is
filling with barium.

(d) There still remains a small part of tho cojcum which does not fill
with barium. Operation showed this was duo to tho lost unreduced
part of tho intussusception.

142 DIAGNOSIS OF THE ACUTE ABDOMEN

per anum, but instead undig^ted material may corae
away, indicating a cause for the colic. Pain ceases
when the bowels are emptied of the undigested or
irritating contents.

Colitis and enterocolitis . — ^These furnish the main
difficulty in diagnosis in young infants, amongst
^\hom acute colitis is very common — especially in

Fio 20 — Dingram of prolapse*) mluasuscepnon

the autumn. Colitis is frequently accompanied by
the passage of blood and mucus per rectum. The
chief distinguishing features are as follows :

(1) In colitis there is usually a stage of prelimin-
ary diarriioea unaccompanied by blood.

(2) The infants who readily fall victims to
colitis are more frequently ill-nourlslied children.
Intussusception usually attacks well-nourished, fat
infants.

INTUSSUSCEPTION 143

(3) In colitis there are more frequent stools, as a
rule containing more fsecal material than in cases
of intussusception.

(4) In colitis there is no abdominal tumour to be
felt, and

(5) The caecum can be felt in the right iliac fossa,
and possibly’ gurgling may be elicited by pressing

on it. There is not that emptiness which is so
noticeable on palpating the fossa in cases of in-
tussusception.

(C) The crises of pain are not usually so severe in
colitis.

(7) In colitis there will sometimes be tenderness
along the whole course of the colon.

Obstructive symptoms and distension are not so

144 DIAGNOSIS OF THE ACUTE ABDOMEN

common in colitis. Tenesmus may be present in
both cases. There may be an epidemic of similar
eases which may help in the diagnosis of colitis. As
mentioned above, a radiogram after ginng a barium
enema vill always settle the diagnosis.

Cases in which the apex of the invagination
protrudes through the anus have to be distin-
guished from prolapsus ani (Figs. 2C and 27).
In the latter there is a ring of prolapsed mucous
membrane seen around a central opening, and the
finger or a probe cannot be inserted between the
mucosa and the external sphincter; in a prolapsed
intussusception the opening of the protruding
portion is towards the posterior aspect of the pro-
jection, and the finger can be inserted between tlic
anterior or lateral portions of the projection and
the anal sphincter. Any intussusception which has
advanced to the anus will be accompanied by con-
siderable distension, and symptoms of intestinal
obstruction.

The late stages of an intussusception of which
the apex has not advanced as far as the rectum,
and which is accompanied by advanced symptoms
of intestinal obstruction or peritonitis (i.c. disten*
sion, frequent vomiting, toxaimia, and collapse) can
only be diagnosed from the other causes of those
symptoms by the liistory of onset and previous
course of the disease.

In children wlio Jiavc passed infancy, and
occasionally in infants, intussusception lias to be
distinguished from IlenodCs purpura, a disease
characterized by abdominal pain, vomiting, the
passage of blood per anum, and frequently ac-
companied by arthritis and an eruption of pur-

INTUSSUSCEPTION 145

punc spots The bleeding from the gut is due
to an effusion of blood into the walls of the
intestine The youngest child in the senes de-
scribed by Henoch was four years old, so the age-
incidence of the two diseases may be a help in
diagnosis. In doubtful cases a very thorough search
must be made for purpuric spots or for joint-
affections Very rarely the two conditions have
been coexistent Here again a barium enema may
clinch the diagnosis

In making a rectal examination of a child with
an intussusception which has advanced to the
descending or sigmoid colon, though it may be
impossible to feel the swollen advancing apex, yet
there may be characteristic cedema of the mucous
membrane of the rectum in advance of the apex
There may be also a certain amount of ballooning
of the rectum

Subacute and chronic intussusception.— There are
some cases of clironic intussusception ^\hich are
accompanied by slight signs of intestinal obstruc
tion, but progress steadily mth repeated attacks
of pain, sometimes at considerable intervals, until
a final serious attack of obstruction occurs Such
cases are accompanied by but slight signs of intes-
tinal obstruction, but progress steadily with repeated
attacks of pain, sometimes at considerable intervals,
until a final serious attack of obstruction occurs In
these cases there may be normal or almost normal
ftccal motions until the final attack, and the
observer is very hkelj to be misled by the chronicitj
or intermittence of the sj/nptoms I have knoum
such a case taken for tuherculous ■penlomtis and
ententis There were loose frccal motions, and an
10

146 DIAGNOSIS or THE ACUTE ABDOMEN

epigastric swelling thought to be rolled up omentum,
but in reality an intussusception In these sub
acute cases the help afforded bj radiograpln after
admimstration of a bismuth or barium meal is of
the utmost value

If after thorough examination there still remains
doubt about the diagnosis of an intussusception,
it should be regarded as less risky to advise explora*
tion of the abdomen than to wait for serious acute
obstructu e symptoms

Intussusception of pelvic colon in old people. —
Intussusception is very rare in old people, but \vhen
it does occur generally affects the sigmoido-rectal
region This leads to frequent hypogastric pains
and tenesmus, whilst mucus, and later blood, are
passed through a rather patulous anus Kectal
examination easily demonstrates the oedematous
apex of the intussusception, which is seldom more
than a few inclics long A malignant growth may
sometimes form the apex

CHAPTER IX

CANCER OF THE LARGE BOWEL
VOLVULUS

If strangulated hernia be excluded, cancer of the
large bowel is the commonest cause of intestinal
obstruction in persons over middle age. The
symptoms are often insidious, and though in most
cases an acute attack of obstruction may be the
direct cause for the calling in of the surgeon, yet
there are many earlier warning signs and symptoms
which should put the observer on guard and cause
a thorough examination to be made.

Early ‘ diagnosis of cancer of the colon will lead to
the prevention of obstruction by earlier treatment.
Por that purpose we consider it useful to include
here a brief summary of the early symptoms.

The pathological character of the cancer may be
either that of a rather quickly growing adeno-
carcinoma or more commonly a scirrhus-type which
contracts as it grows until a small tight stricture
round the bowel is formed (Fig. 28 ). Glands are
involved late, so that early diagnosis is desirable
both to prevent obstruction and to permit a favour-
able attempt at cure.

Tlie symptoms of cancer of the colon prior to an

‘ Vide Z. Cope, “ Carcinoma of the Colon,” Dril, ^led. Jouin.t
1012.

147

148 DUGNOSIS OF THE ACLTE ABDOMEN

nttac^ of acute obstruction inn> bo considered under
the following heads
(1) Symptoms due to boxel ulceration
Diarrhoea and tlie passage of blood and mucus
maj result from ulceration of the bowel Tlic

P<o SS — Drauutg of tie common ring typo of icirrl us c&nccr of UiO
colon wind causes ioteeiinal obstniclton (Irom a fpeclmcn in
St Mary • Hosp tal Museum.)

occurrence of diarrhcea inaj lead patients to assert
that the bowels are regular, whereas the loosenass
IS but secondarj to the irritation caused by the
obstinate constipation Owing to tlie presence of
mucus the condition may wrongl> be diagnosed
mucous colitis

CANCER OF LARGE BOWEL 149

(2) The presence of a tumour, which m the earl>
stages IS often freelv mobile This is uncommon,
since the majority of tlie cases are of the contracting
scirrhoid type with no palpable tumour

(3) Symptoms due to extension to other viscera
The growth may adhere to the bladder, or pelvis
of the kidnej , and cause symptoms referable to the
urinary organs, or may cause gastric symptoms
owing to adhesion to the stomach

(4) Pencolxtis, or inflammation of the tissues
round the colon, may be the first sj mptom of note
A local abscess may form and mask the primary
condition Sometimes perforation of the bowel sud
denly takes place into the general peritoneal cavity,
and diffuse and generally fatal peritonitis ensues

(5) Sxjmptoms of subacute ob'itruciion — These
comprise the same symptoms as tliose caused by
acute obstruction, but they are all of slighter degree
and shock is absent Gradually increasing conshpa^
tion IS often the first abnormality, and if this super-
venes in a person over middle age who has previously
been perfectly regular as to the bowels suspicion
should be aroused and thorough investigation
carried out Diarrlicea sometimes alternates with
the constipation Occasional attacks of distension
and flatulence are common Peristalsis may some
times be seen through the abdominal wall and local
swelling may subside with a gurghng sound due
to passage of flatus through the stricture Pam is
cramp like and due to the peristalsis Sometimes
the patient will describe the pain as travelling across
the abdomen and increasing in intensity up to the
site where the gurgling occurs, and where the
obstruction is situated The pain is often mistaken

150 DIAGNOSIS OF THE ACUTE ABDOMEN

for indigestion, and the accompanying nausea or
sickness attributed to a bilious attack.

(6) Acute obstruction is sometimes the first signifi-
cant symptom which compels attention. IVhen
acute symptoms super\'cnc in a case of cancer of
the colon it nnll usually be found that the ilco-
crecal valve has lost its cfiicicncy so that the
obstructive pressure is forced back into the small
gut. Very severe pain and frequent vomiting may
then occur. When this happens it is frequently
impossible to say what is the exact cause of the
obstruction.

Distension, vomiting, pain, and constipation
occurring in an elderly person, witliout any evidence
of peritonitis, are generally due cither to cancer
of the large bowel, volvulus, diverticulitis, or very
rarely to intussusception or ur®mia, Bcctal
examination to detect a cancer of the rectum and
lower sigmoid, and examination of the urine to
exclude chronic renal disease, are both neccssaiy
procedures. Tlie symptoms of subacute vohTilus
are not always distinguishable from those of chronic •
stricture of tlie bowel.

Diverticulitis, when it causes a stricture, pro-
duces symptoms undistinguishable from those of
carcinoma of the bowel.

Volvulus of the large intestine occurs in two places
—the sigmoid and the ccccal regions. Tlie sigmoid
is by far the most common situation, owing to the
fact that the sigmoid mcso-colon is long and the
base of attachment narrow, so that twisting of
tlie loop more readily occurs. Ilco-caical volvulus
is more rare.

VOLVULUS

151

Sigmotd volvulus causes symptoms of acute or
subacute intestinal obstruction There is usually
a preliminary period daring uhich attacks of
abdominal pain and constipation may occur
The acute attach is signalized by absolute constipa-
tion (verv quickly demonstrated bv administering
a turpentine enema), acute abdominal pain, and

Fio ‘*9 —X raj photop^pl of 8 graoid volvulus showing enormous
d stens on of the coil u! ch extends up to tho left hypochondri im

rapid distension of the abdomen (Accordmg to
Barnard the early appearance of tenderness due to
onset of peritonitis is a distinguishing feature, but
this would only follow quickly uhere there was an
absolute strangulation of the coil, nhicli is by no
means constant ) If the vessels of the loop are com
pletely occluded gangrene of the loop quickly occurs,
and peritonitis ensues rapidly. The great abdominal
distension may seriously impede respiration.

152 DIAGNOSIS OF THE ACUTE ABDOMEN

Subacute sigmoid vohnilus is distinguished by
abdominal pain (chiefly referred to the umbilical
and hypogastric zones), constipation, and gradually
increasing distension. The distended sigmoid coil
may stand out sometimes in the lower abdomen like
the segment of a large pneumatic tyre, but later the
whole abdomen will become generally distended.

Through the diagnosis of volvulus is not always
made before operation the condition should be sus-
pected when early and great distension supervenes
in a case of acute obstruction. Localization of the
distension to the hypogastrium at the outset, or the
standing out of one large coil, may point clearly to
a sigmoid volvulus.

Considerable help can be gained from examina-
tion of a plain X-ray of the abdomen when the
one distended coil may be plainly visible. (Sec
X-ray, p. 151.) VoKulusofthctronsvcrsccolonisscl-
dom seen cxccptaftcrmajorabdominnlopcrntionsin
which the intestines have had to be displaced and
the colon may liavc been twisted in replacement.

Ileo-cacal volvulus gives rise to symptoms similar
to those described under obstruction of the lower
end of the small gut, but in addition there will be
a localized distension due to the dilated ciecum,
observable either in the epigastrium or tlic right
side of the abdomen. Later, the general distension
w'ould mask the local ca;cal dilatation.

Differential diagnosis of obstruction of the large gui
— ^In every case it is necessary first to examine all
the hernial apertures.

There arc four conditions whicii may deceive
flic observer and Ciausc him erroneously lo Ix’hcvc

VOLVULUS

153

that he is dealing with a case of primaty obstruction
of the large bowel. They are :

(1) Colitis with distension.

(2) Urseznia.

(3) Peritonitis.

(4) Reflex paralysis of colon.

Colitis with atonic distension of the inflamed bowel.
— ^There are cases of severe ulcerative colitis in
which either as a direct result of the ulceration or
as a consequence of the toxaemia the large bowel
becomes enormously distended and atonic, so that
organic obstruction is diagnosed. If seen at a late
stage for the first time it may be impossible to
distinguish between the two conditions, but the
long history of symptoms pointing to ulceration of
the colon (diarrheea, ^vith passage of blood and
mucus) in the one case, and the usual history of
subacute obstruction in the other, may help in
determining. In ulcerative colitis tlie obstruction
is never complete and an enema niJI bring au'ay
flatus, whilst the toxic symptoms will be greater.
If seen at an earlier stage a radiogram taken after
a bismuth or barium meal might demonstrate any
obstruction in the colon, but the patients are often
too ill to have this done.

JJrwmia . — ^Abdominal distension and vomiting
are sometimes seen in uncmia, and unless a practice
is made of examining the urine for albumin in
every case of supposed intestinal obstruction in
middle-aged or older persons, serious mistakes ^^’ill
be made. The estimation of the blood-pressure
and the percussion of the cardiac dullness may
throw light on doubtful cases. Symptoms indis-

154 DIAGNOSIS OF THE ACUTE ^VBDOMEN

tinguishable from those of intestinal obstruction
may occur in acute nephritis, chronic nephritis,
and fibro-cystic disease of the kidneys.

Peritonitis . — ^There are some forms of peritonitis
which are accompanied by very slight rigidity of
the abdominal wall, and there are some abdominal
walls in fat, flabby subjects which arc almost
incapable of becoming rigid on account of the weak
and fat-infiltrated muscles. In such patients the
distension and vomiting of peritonitis may be
mistaken for meclianical obstruction. The late
stages of peritonitis arc accompanied by a paralj'tic
obstruction of the bowels, and the Inter stages of
intestinal obstruction arc frequently nccompanicd
by peritonitis, due to organisms escaping through
patclies of local gangrene or malnutrition of the gut.

In the early stage of both conditions diagnosis
is usually clear on considering the history and
symptoms, but in the later stages it may be im-
possible to differentiate.

liejlex paralysis of (he colon . — TJicrc is o deceptive
form of paralytic distension of the colon which on
sev'eral occasions I have known to simulate obstruc-
tion of the large bowel. It appears to be a reflex
result of an acute inflammation somewhere in the
abdomen, and in three cases which I can recall was
a secondary effect of acute cholecystitis, and masked
the primary condition. The t^cending, transverse,
anddescendingcolon may bcdistcnded, and it maybe
difficult to get the bowels to act. These symptoms,
with the pain and vomiting, arc sufficient to divert
from the true cause unless special care be taken.

CHAPTER X

THE EARLY DIAGKOSIS OP STRANGULATED
AND OBSTRUCTED HERNIffl

A STRANGULATED hernia is one of the most dan-
gerous forms of intestinal obstruction. The hernial
orifices through which the abdominal contents
protrude have for the most part hard fibrous edges
which quickly cither cause local necrosis of the gut
at the site of pressure, or cause interference with the
blood-supply in the accompanying mesentery with
consequent gangrene of the gut. It is often very
difficult to make certain whether a hernia is merely
obstructed or whether it is strangulated, for pain and
constipation are usually present in both cases.

The symptoms of a strangulated hernia are those
of intestinal obstruction with the addition of a
painful, tender, and often tense swelling in one
of the hernial regions The type of obstructive
symptoms will naturally vary according to the
part of the gut obstructed in the sac. If jejunum
be caught in the hernia very acute symptoms ensue,
if ileum be obstructed less acute manifestations
result, whilst with large bowel alone in the sac the
symptoms are usually subacute but none the less
serious. Allien omentum alone is strangulated
there will be pain, constipation, nausea, and some-
times vomiting, but the obstruction is never com-
plete and the bowels may be emptied by cnemata.

155

156 DIAGNOSIS OF THE ACUTE ABDOMEN

Shock is a variable factor, but may be very .acute
in some strangulations. The vomiting gradually
becomes ffeculent when gut is strangled.

Since, apart from operation, it is next to impossible
to make certain that there is no gut in the sac, and
inasmuch as mechanical obstruction to the bowel is
ultimately as dangerous ns strangulation, it is well
to treat all painful tense Iicrniai as if they were
strangulated. We consider that, save in the case
of very easily reducible swellings, all painful hernia?,
accompanied by abdominal pain and other symp-
toms of obstruction, should be treated as strangu-
lated hernia: by operation without attempting
taxis. If an anaistlictic has to be given for reduc-
tion it is much better to reduce by open operation.
Fomentations and icebags should be regarded ns
causing unwise and dangerous delay, and taxis
should only be adopted wlicn surgical operative
procedures arc for good reasons impossible.

There are a few practical diagnostic points which
may be considered with each of tlie several varieties
of hernia.

STRANGITLATED INGUINAL HERNIA
It is usually a very easy matter to diagnose
a strangulated inguinal hernia. The patient has
usually been aware of the c.\'istcncc of the hernia
for some time, and may have been wearing a truss.
The sudden coming dovm of the rupture, accom-
panied by abdominal pain, vomiting, and tenseness
and tenderness in the local swelling, make a clear
picture. But mistakes arc possible in the following
conditions :

An inflamed hernia may cause local symptoms

STRANGULATED HERNIA 157

similar to tliose present in one that is strangulated,
but shock is absent, intra-abdominal pain is absent
or slight, and vomiting is quite a minor feature and
never becomes fceculent.

Acute hydrocele of the cord, though rare, has been
known to simulate a strangulated hernia, but the
painful tense inguinal swelling of an acute hydrocele
would not cause so severe vomiting and never
fceculent vomiting, nor would there be any evidence
of intestinal obstruction. Turpentine enemata
would always produce a satisfactory result.

Vomiting due to some other condition may in the
presence of an unreduced inguinal hernia give rise
to a suspicion of strangulation. The vomiting
of pregnancy or that at the onset of appendicitis
may lead to this mistake. But in such cases the
sac is usually neither tender nor tense, and the
contents may be easily reducible. When a cata-
strophe, such as the perforation of an ulcer or
rupture of the gall bladder, happens to occur in a
patient who has an unreduced hernia, there will be
tenderness over the hernial site, and diagnosis has
to be made by considering the history and other
abdominal signs and symptoms.

Inflamed inguinal or iliac glands.— With these the
swelling is usually more diffuse and fixed, and there
are redness and oedema of the skin and subcutaneous
tissues. Vomiting and intra-abdominal pain will
be absent or slight, and fever is sure to be present.

Torsion or inflammation of an inguinal testis may
occasionally closely simulate a strangulated hernia.
The absence of the testide from the scrotum on the
affected side should make one consider the possi-
bility of the condition. In torsion of the testicle

158 DIAGNOSIS OF THE ACUTE ABDOMEN

the local pam is very severe, and vomiting will
begin early in the case but never become fajculent.
Though constipation may be a symptom, eneniata
will produce satisfactory results
When a metastasis of mumps occurs in an inguinal
testis — a very rare occurrence — it might lead to
a diagnosis of strangulated hernia, but there would
be no mtestmal obstruction
It is to be remembered that a retained testis is
often associated with a hernia of the interstitial
variety

Thrombosis or suppurative phlebihs of the \cms
of the spermatic cord causes a painful sw elhng of the
cord and its surrounduigs, but with these conditions
the testicle is swollen and tender and will give the
clue to the condition

On several occasions I have known a subperitoneal
fibroid m pregnant women to cause a swelling
in the inguinal region, and lead to suspicion of
strangulated hernia on account of the coincident
vomiting of pregnancy Careful examination en-
ables one to feel the tumour move separately from
the abdominal wall, and, of course, the vomiting
never becomes fieculent and the tumour is not
usually tender

STRANGULATED FEMORAL HERNIA
A strangulated femoral hernia gi\es rise to more
mistakes m diagnosis than a strangulated inguuial
hernia The hernia is often \cry small and may
easily escape notice in the thick fat often present
m the saphenous region. Sometimes only a small
knuckle of gut comprising but a small portion of
the circumference of the bowel may be caught in

STRANG^ULA'PED HERNIA 1 59

the crural canal, and scarcely any projection may
be felt in the thigh. "When the hernia is of a large
size it consists of a rounded fundus and a narrow
neck or stalk which permits free and often painless
side*to*side movement of the fundal part. This
absence of fixity of the sac may lead the observer
to think that there is no strangulation.

A strangulated femoral hernia might be simulated
by (1) an inflamed inguinal gland, (2) thrombosis
of a saphenous varix, (3) an inflamed appendix
in a femoral hernial sac, (4) a tense and painful
hydrocele of a femoral hernial sac, whilst (5) a
strangulated inguinal hernia has often been wrongly
diagnosed when a femoral sac was causing tlie
trouble.

An inflamed gland is usually more fixed, gives
rise to more oedema and possibly redness of the
parts overlying, and usually results from a primary
cause which may be detected on the’ corresponding
thigh or ano-perineal region. Vomiting and intes-
tinal obstruction are, of course, absent.

A thrombosed saphenous varix would not ordinarily
give rise to vomiting or abdominal pain. If the
thrombosis extends up to the iliac vein there will be
pain and tenderness in the iliac region.

An inflamed appendix in a femoral hernial sac
cannot be distinguished definitely from a strangu-
lated omental femoral hernia before operation,
though by the history of previous attacks of appen-
dicitis it might be suspected. If feculent vomiting
occur it would, of course, be clear that bowel was
strangled in the sac. The presence of an inflamed
appendix would be suspected if hyperesthesia were
elicited within the iliac triangular area.

ICO DIAGNOSIS OF THE ACUTE ABDOMEN

A strangulated inguinal hernia must be distin-
guished by noting that the swelling comes out of
the abdomen medially to the pubic spine and above
Poupart’s ligament.

In general, any swelling in the region of the
femoral canal which suddenly appears or becomes
larger and more painful, and is accompanied by
vomiting or nausea, should be considered os a case
of femoral hernia in need of immediate operation.

In those rare cases in whicli a pouch of the crecum
becomes tightly gripped in a femoral hernia, there
may be no abdominal pain, no vomiting and no
intestinal obstruction, even though the Iwrniated
portion become gangrenous. This fact makes it
all the more necessary to explore any doubtful
tender lump in the femoral region.

OBSTRUCTED AND STRANGULATED U^IBILICAL AND
VENTRAL HERNIffi

Umbilical or para-umbilical hernia is most com-
mon in uomen, and chiefly seen in fat persons. A
very fat w'oman in a surgical ward is nearly always
there on account of gall-stones or an umbilical hernia.

An umbilical hernia usually contains omentum
and frequently large bowel. Small intestine is not
quite so commonly found in the sac. When ob-
struction or strangulation occurs the symptoms are
therefore mucli more likely to be subacute, and
partake more o! the character ot ’large-howdl ob-
struction. The two common mistakes made in re-
gard to umbilical hernia are (1) to overlook a small
hernia lying deeply embedded in fat, and (2) to
think that the hernia is not strangulated because
tlie symptoms arc not very acute. TJic fact that

OBSTRUCTED HERNIA

101

the mortality for operations on strangulated umbili-
cal hernia is three times that for strangulated
inguinal and femoral shows the serious need for more
early diagnosis and interference.

It is quite common
for a patient to have
several attacks of ob-
struction before the
more serious strangu-
lation-attack occurs.
The fact that on
previous occasions the
obstruction has been
overcome by aperients
may lead to an errone-
ous opinion that the
same will occur again.
The symptoms of the
two conditions are at
first similar. It is some-
times only by the most
serious symptoms of
strangulation (gan-
grene of gut or omen-
tum, focal abscess,

even gangrene of the fio 30. — Drawing to bLow bow an

skin overlying the
hernia) that the patient

umbilical hernia may be em-
bedded in and liidden by a fat
abdoTainal wall

and medical attendant

realize the extremely serious nature of tile case.

The diagnosis of an obstructed umbilical hernia
is made on the occurrence of abdominal pain, vomit-
ing, constipation, and local tenderness on pressure
over the swelling, which can always be felt deep in
11

162 DIAGNOSIS or THE ACUTE ABDOMEN

the fat, e\ en if it does not bulge obviouslj on the
surface in the region of the umbilicus The admmis
tration of two turpentine enemata, ^\ith an inter\al
of a few hours, ■« ill determine whether real obstnic
tion of the large bowel exists, and if that is demon
strated it is unwise to wait for the more serious
symptoms of strangulation before advising operation
If small gut be obstructed m the sac sjmptoms will
be correspondingly more acute and \omiting will
soon become fasculent

It IS often difficult to say before openmg tlie sac
whether one is dealing with simple obstruction or
with strangulation

Ventral hemta — The same general remarks apply
here as m the case of umbilical hernia, witli the
exception that small bowel is more commonly
found in the sac, and consequently acute symptoms
are more frequently obsened Abdominal pain,
vomiting, constipation, and local tenderness o\er
the site of a ventral liernia are sufficient to indicate
the need for operation

Obturator hernia is very rare and should be
classed among the mtcmal liemirc, since there is
usually no external swdling, though there may be
tenderness and a little fullness in the upper adductor
region of the corresponding thigh The condition
IS rarely diagnosed before opening the abdomen, but
it IS possible that the Hugh rotation test might give
assistance m diagnosis

CHAPTER XI

ACUTE ABDOMINAL SYMPTOMS IN PREONANCY
AND THE PUERPERIUM

Acute abdominal pain in a pregnant woman is
always a source of special anxiety, both from the
maternal and the foetal point of view. Exploratory
operations are not lightly to be advised on account
of tlie risk of abortion, and one therefore needs to
be veiy sure of the indications of the various acute
diseases needing intervention before advising the
abdomen to be opened.

The following conditions giving rise to acute
abdominal symptoms may be met with during
pregnancy or the puerperium :

(1) Persistent vomiting,

(2) Ectopic pregnancy.

(3) Retroverted gravid uterus.

(4) Threatened abortion.

(5) Sepsis following attempts at abortion.

(6) Pyelitis.

(7) Degeneration in a fibroid.

(8) Spontaneous rupture of the uterus.

(9) Appendicitis,

(10) Perforated. gastric ulcer.

(11) Torsion of an ovarian cyst-pediclc or a

pedunculated fibroid.

(12) Pelvic peritonitis or cellulitis.

103

164 DIAGNOSIS OF THE ACUTE ABDOMEN

Persistent vomiting. — The morning vomiting of
pregnancy usually begins in the second and- con-
tinues through the third month. As a rule it does
not cause any anxiety, but when accompanied by
any abnormality in the abdomen it may give rise
to doubt. On several occasions I have known seri-
ous doubt occur in pregnant women who were
vomiting and also had a slightly painful swelling in
the right inguinal region. It was tliought that a
strangulated inguinal hernia might be causing the
symptoms, but examination showed in each case
a uterine fibroid which had risen out of the pelvis
with the enlarging uterus and hod simulated a
hernia by bulging out the inguinal canal. TJie
vomiting in such cases takes place without reference
to any pain in the swelling, and it is possible to feel
any intra-abdominal swelling move independently
of the abdominal wall on deep respiration.

I have also known the vomiting of early preg-
nancy, when accompanied by slight pelvic pain due
to congestion or constipation, to be mistaken for
appendicitis, but careful pelvic and abdominal
examination, and a close attention to the symplom-
scqucnce, should exclude this condition.

The excessive vomiting due to the toxfcmia of
pregnancy does not concern us here, but it is neces-
sary to make sure that there is not any serious intra-
abdominal lesion before diagnosing hyperemesis
gravidarum.

Ectopic pregnancy is so important and common
that the next chapter is devoted to thatsubject alone.

A retroverted gravid uterus, or, os it was well
termed by Matthews Duncan, “ the disease of the
third and fourth montlis of pregnancy,” may give

DURING PREGNANCY

1G5

rise to acute abdominal pain felt chiefly in the
hypogastrium, where the distended bladder is
situated. The fact of pregnancy considered along
with the presence of a hypogastric swelling (larger
than the uterus should be for that time of gestation),
the occurrence of pain, nausea, and retention of
urine (or maybe dribbling incontinence), would
cause one to suspect the condition, which would be
easily diagnosed after the urine had been drawn off.

Threatened abortion sliould cause no difficulty in
diagnosis when pregnancy is known to exist, since
the uterine bleeding with the lumbar backache and
hypogastric pain, and the absence of evidence of
any other local abnormality, should sufficiently
determine the condition.

Sepsis following attempt to produce abortion.-— It
is unfortunately not unkno^vn for women to try
either to produce abortion on themselves or to
persuade some lay person to attempt a similar dis-
service for them. Sepsis may follow these attempts,
and when the doctor is called in it may be diffi-
cult to obtain any history of interference. The
sepsis may take the form of a peritonitis, a septi-
caimia, or both. There is generally bleeding from
the uterus. In any case, therefore, of bleeding
from the uterus in a woman who has had a
period of amenorrheea and in whom abdominal
pain, vomiting, and fever suddenly present them-
selves, one must bear in mind the possibility of
uterine sepsis. Septiciemia and peritonitis in such
cases are usually rapid and virulent. The onset is
unlike that of any other abdominal condition, and
the pain may not only be felt in the hypogas-
trium but may bo referred to the back or down

166 DIAGNOSIS OF THE ACUTE ABDOMEN

the legs. Careful bimanual examination wll
determine an enlarged softened uterus and may
exclude any other pelvic condition. In any such
case it is -wise to have a consultation with a fellow-
practitioner before deciding on any course of action.

Pyelitis is not an uncommon complication of
pregnancy. It occurs usually about the fourth
month of gestation, and its onset may liavc some
relationship to the pressure of the growing uterus
upon the ureters, especially the right ureter, for
the condition is more common on the right side.

The symptoms commonly start with a rigor or
feeling of chilliness, and the temperature quickly
rises to 103® F. or thereabouts. At the same time
pain is felt in one or other loin (generally the right)
under the costal margin. Pressure at the erector-
costal angle produces pain. There may be some
frequency of and pain on micturition, but this is
not constant. There is as a rule no rigidity of
abdominal mus<^cs. In some cases tlic patient
does not feel ill, whilst at other times there may be
severe malaise. Examination of the urine shows
turbidity, albuminuria, and the presence of pus in
small quantity. Bacteria (usually bacillus coH com-
munis) will be detected on microscopical examina-
tion. The albumin may not be more than is to be
expected to correspond .with the pus.

When on tlie right side differential diagnosis
TnViSt be. it'sm a|vp^wdwy.t\s. Tlus Is. »ASU9.Uy
easy, for appendicitis seldom starts with a rigor,
infrequently causes such high fever as 103® or 104® F.,
and is often accompanied by local rigidity, and not
so frequently by any urinary trouble. Examination
of the urine sliould settle the diagnosis.

DURING PREGNANCY 167

Appendicitis and perforated gastric ulcer are
misfortunes that may overtake the pregnant as any
other woman, and they should be' diagnosable
readily by considering the symptoms carefully.
Sometimes when they occur in the puerperium they
may be mistaken for the results of puerperal sepsis.
The symptoms, however, should be readily inter-
preted if the possibility of tlieir occurrence be borne
in mind.

In the puerperium also it is not uncommon for a
dermoid or other ovarian cyst to become inflamed
or undeigo torsion^ owing to the contusion and dis-
placement consequent on the labour. There will be
acute abdominal pain, fever, vomiting, and a tender
hypogastrium, wliilst a rounded swelling will be felt
near the uterus but separate from it. A distended
bladder should be e-\cluded by catheterization, and
a twisted fibroid by noting the relation to the
uterus.

Red degeneration or necrobiosis of a uterine fibroid
is particularly prone to occur during pregnancy.
The symptoms are pain felt locally in the fibroid,
which can be palpated through the abdominal wall,
slight fever, and nausea or vomiting. In any patient
who is kno^vn to have a fibroid and to be pregnant
such symptoms would point to red degeneration, and
in such cases it is sometimes possible for the fibroid
to be enucleated without disturbing the pregnancy.

rsjpiijre of ihe pregnoni ziiems is a
very rare condition leading to severe shock and signs
of internal haemorrhage. For details one must
consult an obstetrical tottbook.

Pelvic peritonitis may ensue after childbirth.
Sometimes this may be septic in nature, but quite

165 DIAGNOSIS OF THE ACUTE ABDOMEN

commonly it may be of gonorrhoeal origin. Any
vaginal discharge in the patient or the presence of
infection of the baby’s conjunctival sacs might
give the clue. Hypogastric pain and tenderness,
vomiting or nausea, and bilateral tenderness in
the uterine fornices will be demonstrable.

ACUTE ABDOMINAL DISEASE PECULIAR TO WOMEN
APART FROM PREGNANCY

Acute salpingitis. — ^Acute salpingitis is most
commonly due to infection with the gonococcus.
Another frequent cause is infection with the staphy-
lococcus or streptococcus. It can also be caused by
the bacillus coli communis or the pneumococcus.

Symptom and signs , — Tlie picture is tJmt of an
attack of pelvic peritonitis — liypognstric pain,
nausea or vomiting, and fever which may reach as
high as lOS*”. Examination shows tenderness on
pressure in both iliac fosste and in the suprapubic
region. In some cases the lower abdomen is rigid
and moves badly on respiration, and there may be
considerable distension. Vulval examination may
show traces of a gonococcal infection, or a purulent
vaginal discharge may be present. Palpation in
the lateral fornices may cause pain.

Diagnosis . — The common and chief cUfTiculty is
to distinguish appendicitis from salpingitis (see
Chapter V).

The symptom-sequence is usually more cliarac-
teristic in appendicitis, and the pain often more
strictly limited to the right side. In salpingitis
it is common for the pain to be worse on the left
side than on the right — an occurrence but rarely
seen in tlie early stages of appendicitis.

IN lYOMEN APART FROM PREGNANCY 16 D

A vaginal discharge m which gonococci are
detected vould be significant.

^Mlen pelvic peritonitis follows childbirth it may
not shov itself for a week or more after the birth.

It IS frequently very difficult and almost im-
possible to make quite certain u hether the appendix
or salpinx is primarily at fault.

Pyosalpinx. — ^Many cases of salpingitis quieten
down and form a local collection of pus vithin
the Fallopian tube — pyosalpmv The condition
IS usually bilateral. For a time symptoms may
abate and be almost negligible, but sooner or
later the infection spreads and an extension of
inflammation occurs. There will be the symptoms
of pelvic peritonitis as in the cas^ of salpingitis,
but m addition there will be felt a bilateral tender
swelling m the pouch of Douglas. The symptoms
m a ruptured pyosalpmx are often the more serious
since there is frequently secondary infection of the
pus sac by organisms other than the gonococcus.

An ovanan cyst with twisted pedicle gives rise to
acute symptoms. Hypogastric pain, vomiting, and
the presence of a tender suellmg m the lower
abdomen are the prmcipal features.

The vomiting comes on almost as soon as the pain,
so that there is less likely to be an interval between
the initial pain and the vomiting as is usual in
appendicitis. Witii an ovarian cyst there will be a
definite, rounded, tender swellmg to be felt cither by
palpating the hypogastnum or by pelvic examina-
tion, If the case be not seen early, peritonitis nith
accompanying rigidity may pre\ ent the full outline
of the tumour being felt, and it may be difficult to
distinguish fiom other causes of pelvic peritonitis.

170 DIAGNOSIS OF THE ACUTE ABDOMEN

e.g. acute salpingitis vrith serous effusion, but the
symptoms of a t%vistcd ovarian cyst are usually the
more acute.

Torsion 0 / pedicle of hydrosalpinx . — ^With this
the symptoms are similar to those of an ovarian
cyst vrith twisted pedicle, though usually slighter in
degree: pain, nausea or vomiting, and a tender,
movable swelling in one or other vaginal fornix.
In the presence of even the slightest menstrual
irregularity it would be impossible certainly to
exclude an unruptured ectopic gestation.

In every doubtful .case of acute abdominal ilis-
case in. women it is necessary to pass a catheter to
make sure that the bladder is empty before mak-
ing a final decision.

CHAPTER XII
ECTOPIC GESTATION

By ectopic gestation is meant the development of
a fertilized ovum in any place other than the
uterine cavity. The rupture of such a gestation
sac is a comparatively common occurrence with
fairly characteristic symptoms, yet it is commonly
misdiagnosed.

Fertilization of the ovum probably normally
takes place in the Fallopian tube, and any slight
cause may detain the developing ovum, prevent its
further progress and lead to an ectopic gestation.
A fertilized ovum has beep known very rarely to
develop in the substance of the ovary, but this
condition is of little practical importance, since
one cannot clinically distinguish it. The common-
est place for ectopic development of the ovum is in
the ampullary part of the Fallopian tube. More
rarely it is found in the isthmial part of the tube,
and more rarely still it may develop in the tubo-
uterine section of the tube, or in a rudimentary
cornu, which for clinical purposes must be included
in the same group (Fig. 31).

In a tubal gestation growth of the ovum leads to
distension of the tube, whilst the eroding action of
the villi leads to a thinning of the wall. Gradual
oozing of blood may take place into the peritoneal
171

172 DIAGNOSIS OF THE ACUTE ABDOMEN

cavity from the eroded area, or any sudden strain
may lead to rupture of the tube. Sometimes the

ovum IS extruded through the end of the tube into
tlie peritoneal cavity by a process ^vcll termed
“ tubal abortion,” or the embryo may die in consc-

ECTOPIC GESTATION

173

quence of hsemorrhage into the sac, or rupture of
the sac into the lumen of the tube, and thus may
be formed a tubal mole.

If the embryo lives, primary rupture of the sac
occurs usually within the first eight weeks of preg-
nancy, though in the case of a tubo-uterine or
interstitial gestation-sac rupture need not occur till
pregnancy has advanced to the third or fourth
month.

Rupture of the sac causes acute abdominal symp-
toms which usually subside with the formation of a
collection of blood-clot in the pouch of Douglas
(pelvic hiematocele), but in some cases death may
rapidly occur from the great internal hajmorrhage.
It is exceptional for the sac to rupture into the
broad ligament.

If the foetus continues to develop after primary
rupture of the tube severe symptoms may be caused
at a later date by secondary rupture into the
general peritoneal cavity.

Ectopic gestation often results from the first
conception of a woman who has been married some
years, or in a parous woman who has not been preg-
nant for several years.

Symptoms and diagnosis. — patient with an
ectopic gestation may seek advice for abdominal
pain :

(2 ) Before the ssc hss ruptured.

(2) At the time of primary rupture of the

sac.

(3) Some days or even weeks after the

rupture.

174 DIAGNOSIS OF THE ACUTE ABDOMEN

(1) Symptoms and diagnosis before (he sac has
ruptured.

If the serious complications ensuing on tlie ,
rupture of a gestation-sac arc to be avoided it is
essential tliat the condition should, if possible, be
diagnosed before the tube has given way. Some-
times there are few if any symptoms premonitory
of rupture, but frequently there are indications of
value which enable one to make a diagnosis with
suflicient probability. There was a time when it
was a rarity to diagnose and remove an inflamed
appendix before it ruptured, now it is considered
something of a reproach to allow an appendix to
perforate before surgical advice is obtained. In like
manner though not to the same degree it is likely that
in tlie future greater attention will be paid to the
correct diagnosis and operative treatment of a tubal
pregnancy before primary rupture Ims occurred.

In a typical case '(such as is seldom seen) the
symptoms and signs u'ould be :

Amenorrhoca (for one or two months).

Hypog.astric pain.

Uterine bleeding.

Local iiypogastric tenderness on pressing into
pelvis toward one side.

Small tender swelling in tlic lateral fornix.

The passage of a membrane per vaginam.

Amenorrhwa . — ^Tliough in type-cases one or two
periods may Iiavc been missed, the breasts may be
slightly enlarged and full, and even sickness in the
morning noted, yet such definite symptoms are
rather exceptional.

Tlierc is, however, nearly always some slight

ECTOPIC GESTATION 175

irregularity of menstruation, and care must be
taken to ascertain exact particulars as to that event.
The patient must be asked (1) when was the last
period ; (2) if that period w'as before or after the
normal time, noting a delay or advancement of as
short a period as a day in women who are usually
regular to the day ; (3) whether the loss at the last
period was less or more than usual ; (4) whether any
slight loss has occurred since the last regular period.

Since the gestation-sac of an embryo under a
month old may rupture, or abort through the end of
the tube, it is not absolutely necessary for there to
be any irregularity of menstruation. Not uncom-
monly the bleeding from the vagina which accom-
panies tubal abortion is mistaken by the patient
for the normal menstrual period, for it may
coincide exactly with the expected menstruation.
Usually the loss is less or greater than normal, and
is antedated or postdated to the regular period
by a day or several days. Sometimes what ^vas
apparently a normal period ceases for a few days,
and then bleeding recommences. All these slight
irregularities need to be noted.

Abdominal pain felt chiefly in the hypogastric
or iliac regions may be the chief complaint. Taken
in conjunction with the vaginal bleeding these pains
may suggest both to patient and doctor a threaten-
ing abortion. The pains are probably due to
repeated slight intra-peritoneal hsemorrhage, or to
the contractions of the Fallopian tube.

Uterine bleeding has been referred to aboi'C. It
is not constant. The blood as it comes away from
the vagina is stated to be darker than the normal
menstrual loss, but this is not of much value

17C DIAGNOSIS OF THE ACUTE ABDOMEN

in diagnosis. Wiat is of greater importance, if
it occur, is the passage of a decidual cast of the
interior of the uterus. TJiis seldom occurs till
the embryo is dead, or aborted into the abdominal
cavity, and often occurs after the operation for
removal of a ruptured sac has been performed.
If it occur at the time of the early griping pains
it is of the greatest importance in diagnosis. The
shreds of membrane do not show any chorionic vilU,
and can thus be distinguished from an embryonal
uterine sac. They should be floated out in water,
so that the full size and shape may be ascertained.

Hj/poga^tne tejjdemm may be detected on the
side of the lesion if the fingers are gently pressed
well do^vn behind the pubis. The abdominal wall
is not rigid.

Bimanual examination reveals a small rounded
tender movable swelling to one side of the uterus
in one or other lateral fornix corresponding to the
side Nvhere the pain and tenderness arc elicited.
The uterus will also be felt slightly enlarged.

To sum up : if the patient and tlie doctor think
that pregnancy Jias begun, if there be irregular
hypogastric pain more on one side than the otlicr,
and if with slight uterine bleeding a tender rounded
movable lump be felt to one side of a slightly
enlarged uterus, ectopic pregnancy sliould be
diagnosed and operation strongly adv'ised. On
one occasion when on such grounds I had diagndsct?
extra-uterine pregnancy and advised operation, the
patient went for confirmation of the diagnosis to a
hospital. IMiilst w'aiting in the out-patient depart-
ment of the hospital she collapsed from internal
bleeding and had to be operated on promptly. It is

ECTOPIC GESTATION

177

possible and should be a more frequent occurrence
to diagnose the condition before great internal
hscmorrhage occurs

Differential diagnosis — Grandm, in reference to
tubal gestation, observes “ The man who suspects
every woman of havmg the condition is the man
who is least liable to err m diagnosis ” It is fre-
quently misdiagnosed because infrequently con
sidered An early unruptured tubal pregnancy
needs to be distinguished from
Gastntis
Appendicitis

Threatened uterine abortion

Pyo- or hydrosalpinx

Small ovanan or broad ligament cysts

It is only by the casual observer who has not
exammed the patient that the colicky pain of an
ectopic pregnancy threatening to rupture can be
mistaken for gastritis The position and nature
of the pam should direct attention to the pelvis,
where examination will soon provide facts for
correct diagnosis

If the gestation be m tlic light tube it is easily
mistaken for appendicitis Some of the main
points in diagnosis may be tabulated

Menstruation

Uterine bleeding
Initial pain
Fever

Vomiting or nausea
Bimanual examination

SytDptomB of on
unruptured inflamed
pelvic appendix
Usually regular

Usually none
Uplgastnc
SI gbt fever
Present

Tenderness but no
movable lump

Symptoms due to an
unruptured (but poss bly
leaking) tubal gestation
Usually some irrcgu
laritv

Usually present
IlyTogastrie
Usually no fever
Unusual

A tender rounded mov •
able swelling to one
side of the uterus

12

178 DIAGNOSIS OF THE ACUTE ABDOMEN

If tlie appendix is not situated in the pelvis there
can be little likelihood of mistake. Neither with
a pelvic appendicitis nor with a tubal gestation, is
there, as a rule, any rigidity of the abdominal wall.

A threatened uterine abortion is often difficult to
distinguish, and on several occasions I have known
uterine curettage performed for what was thought
to be an incomplete abortion, but was in reality a
tubal gestation. Bimanual examination ought to
distinguish, for if it be definitely decided that preg-
nancy has begun, and there be uterine bleeding,
pelvic examination will show in tlie one case a
slightly enlarged uterus with a small swelling to one
side, and in the other case a larger uterus with no
swelling in the lateral fornix.

The greatest difficulty in diagnosis would be in
the case of an intra-uterine pregnancy complicated
by a pyosalpinx,- hydrosalpinx", or small ovarian
cyst. If severe abdominal pain occurred with any
of these it might be impossible to diagnose with
certainty, but abdominal section would be indicated
in any case.

(2) Symptoms and diagnosis at the time of rupture
or tubal abortion with profuse intra-peritoneai
bleeding.

Rupture of a tubal gestation is probably the
commonest cause of sudden death in young women
who have previously been in perfect bealtii. it
brings many more to the gates of death.

The symptoms are usually clear :

Sudden abdominal pain.

Vomiting.

Faintness or actual fainting.

ECTOPIC GESTATION 179

Sudden anasmia and collapse with small
rapid pulse and subnormal temperature.

A tender tumid abdomen.

Free fluid in abdominal ca% ity.

Tenderness on pressing finger against Doug-
las’ pouch.

The pain is sometimes hypogastric, sometimes
more general oi even epigastiic, occasionally pain
IS felt over the cla\ icles or even in the supra-spinous
fossa. Theamemia should be looked for especially
m the hps, tongue, and under the finger nails. The
scleiotics also have a particularly white appearance,
and there is sometimes a dark ring round the eyes.
Restlessness and occasional deep sighing respirations
may indicate the severe internal hremorrhage.

The pulse rate is by no means always a good guide
as to the bleeding, for in some people it takes a
very large haemorrhage to cause much increase in
rapidity, and m others rapid compensation and
lestoration of the circulation occur.

Examination of the abdomen will show a flaccid
but tender abdomen, with some fullness and (ex-
ceptionally) slight resistance to palpation in the
hypogastnum Free fluid may be demonstrated,
but it is unnecessary and unwise to do so The
pelvic peritoneum will be tender and a sw clhng maj
possibly he detectabie in one latetsl forni\. The
important points to pay attention to are the sudden
onset, the fainting attack, the graac anaimia, feeble
pulse, and subnormal temperature

Differential diagnosis must be made from several
of the very acute abdommal catastrophes, such as
perforation of the stomach, duodenum, or gall-

180 DIAGNOSIS OF THE ACUTE ABDOMEN

bladder, acute intestinal obstruction, acute pan-
creatitis, acute perforative appendicitis, or torsion
of the pedicle of an ovarian cyst. The history of
the case, the sudden onset and the persistence of
the extreme pallor and subnormal temperature
without rigidity of the abdominal wall in a patient
previously well, except for some slight irregularity
of menstruation, seldom or never leave room for
doubt.

It may be impossible clinically to distinguish
rupture of an ectopic pregnancy from severe
hcemorrhage from a Graafian Jollich. The latter
is ,a very rare occurrence and usually unaccom-
panied by any of the signs of pregnancy. In
a case seen by the author the palpitation, rapid
pulse, and nerv’ous condition of the patient were
by one observer attributed to cardiac weakness
and hysteria. The low blood-prcssurc as shown
by the sphygmo-manometer exposed tlic truly
critical condition of the patient.

(8) Symptoms in Cases with Subacute Ecemorrbage.

We must now consider diagnosis after repeated
bleedings have caused a liajmatocclc to form.

Many cases come for diagnosis a sliort while after
an acute rupture of tlie sac, or after repeated slight
haemorrhages have led io the formation of a hccmatocele.
At the time of obscr\'atxon the bleeding may liavc
stopped and tlie patient may have recovered
sufTiciently to get about again. Tlic previous
serious symptoms may have been attributed by tlie
patient to a simple fainting fit, or the doctor may
have thought the trouble due to a cardiac attack.

ECTOPIC GESTATION

181

This mistake could only arise m those patients who
have had moderate internal hasmorrhage, for m the
extreme degrees the grave nature of the case cannot
be missed.

After a moderate hiemorrhage the slight collapse
is quiclJy recovered from, the pulse may become
normal, and the temperature from subnormal may

Pio 32 — Diagram of a hasmstocelo (from tho front} (Tbo black area
indicates firm and older clot the dotted portion represents looser ond
more recent clot )

become slightly febrile. Wicn there have been
repeated slight hasmorrliagcs there may be no
history of acute collapse, but usually with repented
attacks of pain the patient ^m 11 have felt faint
Such a patient comes for advice either for ab-
dominal pain and ^\eakncss, or for pain and uterine
hcomorrhage. Occasionally retention of urine may
cause advice to be sought

182 DIAGNOSIS OF THE ACUTE ABDOMEN

Diagnosis is made by considering the history of
repeated attacks of hypogastric or iliac pam, the
irregularity m menstruation, and the conditions
found on examination, which are as follows

(1) The patient looks anaimic

(2) The temperature is normal or febrile
(100° F or 101° F)

(3) Tiie pulse is eitlier normal or increased
(100 to 120) m frequency

(4) There is a fullness of tlie lower abdomen
(due slightly to distension, but chieflv to the
blood clot)

(5) The lower abdomen is tender on pressure,
especially on tlic side of the tubal gestation

(6) Rigidity of the abdominal wall is absent,
though the patient may show resentment of any
deep pressure by contracting tlic muscles

(7) There is usually some uterine bleeding

(8) Pelvic exammation re\e'ils a fullness and
resistance in one or botli hteral forniccs
Sometimes a definite harder swelling may be
felt If the blood clot is firm, bimanual
examination reveals a definite tumour filling
the pouch of Doughs Pam is alwajs elicited
on pressure on the swelling (wliether vaginally
or per abdomen)

(9) There may be retention of urine or fre-
quency of urination

(10) On two occasions I ha^c obtained a
positiN c obturator or thigh rotation test (see
Chapter III)

Additional c\ idcnce of intcmnl hrcmorrliagc innv
sometimes be obtained m the form of a bluish or

ECTOPIC GESTATION 1 83

purplish discoloration in the region of the navel
(Cullen’s sign). Such discoloration, however, is
very inconstant.

Vomiting sometimes occurs with the attacks of
abdominal pam, but is not a constant nor import-

Fio 33 — Ciagratn of a h»tnatoc«le (lateral view]

ant feature. Constipation may be present. Diag-
nosis is usually clear from the above symptoms and
signs. VTien the pregnancy has advanced two or
three months the softening of the cervix and enlarge-
ment of the breast may help in diagnosis (Fig, 33),

184 DIAGNOSIS OF THE ACUTE ABDOMEN

Differential diagnosis is sometimes difficult from
pelvic appendicitis, pyosalpinx, or retroverted
gravid uterus.

Pelvic appendicitis may give rise to nearly all.the
signs and symptoms of a small pelvic hiematocele,
and the two conditions are frequently confused
in diagnosis. Hypogastric pain, vomiting, local
tenderness, slight fever and tenderness on rectal
or vaginal examination are commonly present in
both conditions. Even the tliigh-rotation test may
be positive in botli cases, and in neither instance
should one expect to find abdominal-wall rigidity.
The main points of distinction arc that in an ectopic
pregnancy there is nearly always 5omc irregularity
of menstruation or even definite nmenorrheea for
a month or two, usually uterine bleeding, possibly
the symptoms of early pregnancy and the ap-
pearance of anaemia, and the history of onset is sug-
gestive of internal luemorrhage and quite different ,
from the usual onset of appendicitis in wliich the
symptom-sequence may be definitely helpful in
diagnosis.

With a pyosalpinx there should not bc.mcnstnial
irregularity, though menorrhagia is not infrequent,
and there should be a history of previous pelvic
inflammation or of leucorrlicea, endometritis, or
definite gonorrhoeal infection. The uterine cervdx
will not be softened in pyosalpinx^ and pain on
micturition and retention of urine are less likely to
occur.

A retroverted gravid uterus miglit be confused
with an ectopic pregnancy which had gone on to the
third or fourth month of gestation. Both may
cause retention of urine. But if the bladder be

ECTOPIC GESTATION

185

emptied by catheter it should be possible to make
out the determining factor in diagnosis, i.e. the
absence or presence of the uterine fundus from the
normal position. The bleeding from a retroverted
gravid uterus would be that of fresh blood indicating
threatening abortion, the blood lost in an ectopic
gestation would usually be darker. Anremia would
only be observed in the ectopic pregnancy.

If the foetus of an ectopic pregnancy survive the
rupture until the later months of gestation, the
condition will cause tlie formation of an abdominal
tumour in which the foetal parts may be felt easily
under the abdominal wall, while at tlic same time
the symptoms of pregnancy will be very evident.
It is possible that acute symptoms might occur at
this stage, but this is rare and need not be con-
sidered here.

CHAPTER XIII

CHOLECYSTITIS AND OTHER CAUSES OF ACUTE
PAIN nr THE RIGHT UPPER QUADRANT
OF THE ABDOMEN

Severe pain arising in, or chiefly localized to, the
right hypochondriac region is usually due to one
of the following conditions :

Cholecystitis.

Biliary colic.

Inflamed or leaking duodenal ulcer.

Rupture of gall-bladder or a biliary’ duct.

Hepatitis.

But one always needs carefully to exclude

Appendicitis.

Renal pain or colic.

Pleurisy or pleuro-pncumonia.

The gall-bladder and cystic duct may be regarded
as a vermiform muscular tube which has a dilated
extremity and opens mediately through tlic com-
mon bile-duct into ’the duodenum. In certain
respects, therefore, it is analogous to the c»cal
appendix. Further, it is common for a stone to
stop up the cystic duct just as a concretion may
occlude the lumen of the appendix. The chief
difference between the two structures lies in the fact
that f®cal material is common in the cjccal appendix

CAUSES OF ACUTE PAIN 187

but never seen in the gall-bladder, though the
bacillus coli communis is frequently found in the
latter.

Cholecystitis, or inflammation of the gall-bladder,
may occur with or without the presence of gall-
stones. Infection may gain access either from the
blood-stream (more commonly) or from the intestine
via the biliary ducts. The intensity of the inflam-
mation varies greatly. Sometimes there is a mere
catarrh of the mucous membrane lining the gall-
bladder, which may be full of clear or bile-stained
mucus, while frequently the inflammation involves
the whole thickness of the bladder-wall, which
becomes oedematous and friable. In extreme cases
gangrene of part or the whole of the gall-bladder
may occur. The inflamed viscus may have omen-
tum adherent to it, but this does not occur quite so
frequently as with an inflamed appendix. Rarely
both gall-bladder and vermiform appendix may
be simultaneously inflamed.

The contents of an inflamed gall-bladder consist
either of clear or bile-stained mucus, or of muco-
purulent bilious material sometimes containing
much cholesterin in suspension, or accompanied by
gall-stones. lYhen gall-stones are present they
may belong to any of the different varieties — the
large^ barrel-shaped stone, the multiple small
facetted stones, or the innumerable black pigment-
calculi like small jet beads, which arc sometimes
embedded in a tar-like matrix.

Wien a gall-bladder is inflamed the ‘ overlying
liver substance sometimes enlarges and projects
downwards from the liver margin, forming one
variety of Ricdl’s lobe.

188 DIAGNOSIS OF THE ACUTE ABDOAIEN

The symptoms of cbolecsrshhs are :

Pam.

Vomiting
Fe\ er

Constipation

Local tenderness m right hjpochondrium.
Sw elling in region of gall bladder (sometimes)
Rigiditj of overlying muscle (sometimes)
Jaundice (rarely)

The pain of cholecystitis \arie5 according to
ivhether or not there is a stone attempting to pass
along the cystic duct When there is no stone the
pain IS generally localized to the region of the gall-
bladder, or if there be contiguous peritonitis (ns is
not infrequently the case) the pain may be diffuscil
over the right hypochondriac region and c\en felt
on top of the right shoulder If the h\ or and gall-
bladder are much enlarged downwards the pun
may extend doivn almost to the iliac fossa

^ATien there is a stone m the neck of the gall-
bladder or in the cystic duct the pain radiates also
to the area beneath the inferior angle of tlie right
scapula This corresponds to the level of distribu-
tion of the eighth dorsal segment from nhich the
gall bladder deriv es its mam ner\ c supply . In
uncomplicated cases pim i*: not felt m tlic right
acromial or clavicular regions

Vonntmg is also a variable feature It is slight
in severity when there arc no gall-stones ami no
peritonitis, but nlien either or both of these arc
present there may be constant vomiting or con-
tinual retching and bringing up of bilious material
Local tenderness over the gall bladder is a con-
stant feature, and frequently ivhcn there is no

CAUSES OF ACUTE PAIN 189

muscular rigidity one can feel the rounded fundus
of the viscus projecting below the inferior margin
of the liver. Usually tlie swelling is small, but
occasionally it may be of considerable size and
bulge down A\ell into the right iliac fossa or into the
umbilical region.

When the inflammation has spread to the parts
around the gall bladder there is usually rigidity of
the right upper quadrant of the abdominal parietes,
which thus protects the inflamed area In some
cases of cholecystitis, however, there is no rigidity.

Fever is not usually high, but vanes from 100° to
103'^ r, according to the extent of the inflammatory
process and the virulence of the infection If the
bile-ducts are simultaneously infected it is common
to get higher and more irregular fever, occasional
rigors, and in general more serious symptoms

Constipation is usual, and is more obstinate
if there be local peritonitis affecting the neigh-
bouring coils of intestine

The pulse is not of much diagnostic value It
may remain steady and slow in spite of acute
inflammation of the gall-bladder, the presence of
biliary calculi, or even local peritonitis A rapid
pulse m cholecystitis may be indicative of severe
toxaemia, either from extending peritonitis or merely
from toxic substances absorbed from the bile-ducts
and gall-bladder

Jaundice is not usual in cases of simple chole-
cystitis, nor IS it the rule even when gall-stones are
present, but there is frequently a history of jaundice
occurring after previous attacks of acute abdominal
pain. This A\ould suggest the previous passing of
a gall-stone

190 DIAGNOSIS OF THE ACUTE ABDOMEN

DifEerential diagnosis. — Cholecysiiii'i is most com-
monly mistaken for appendicitis, or an inflamed
duodenal ulcer.

mnamed ascending appendix

The symptoms — pain, vomiting, constipation,
fever, leucocytosis — are very similar to those of
appendicitis, but the site of localized pain is in the
one case in the right hypochondrium and in the

CAUSES or ACUTE PAIN 191

other m the right lumbar or iliac regions If any
swelling be palpable its continuity with or dis
tinction from the liver is of prime importance in
diagnosis It must be allowed that there arc some
cases, especially in fat subjects with a rather low-
lying inflamed gall bladder accompanied by local
peritonitis and rigidity, in which a definite differen
tiation from appendicitis with local abscess is almost
impossible before operation A previous history
of jaundice or biliary colic may be of assistance, oi
an account given of previous attacks suggestive of
appendicitis might point to that disease It must
not be forgotten that it is not unknown for the two
diseases to occur simultaneously
Inflamed duodenal ulcer. — In the case of a duo*
denal ulcer which is threatening to perforate and
has caused periduodenitis the local findings may be
similar to those of cholecystitis with local perito-
nitis, but a careful inquiry into the history will
distinguish The pain which comes on about two
and a half hours after meals and is relieved by
taking food, the bringing up of water brash ” and
acid eructations, tlie attacks of flatulence, and pos
sibly the occurrence of melicna may give a clear
picture of ulcer If there be time, and the con
veniences, the diagnosis of ulcer may be confirmed
by noting deformity of the duodenal cap and a
rapid emptying of the stomach as observed bj
X rajs after administration of a barium meal
Retroperitoneal perforation of a duodenal ulcer
may be attended by severe collapse at the onset,
but the condition quickly locahzes and leads to
tenderness and swelling in the nght loin The
perinephric tissues become cedematous, and there

192 DIAGNOSIS OF THE ACUTE ABDOMEN

may be frequency of micturition and even Ii’cma
tuna from the irritation of the renal pehis There
IS great pam on pressure at the erector costal angle
The diagnosis is dilRcult, since a primary renal
condition is likely to be suspected
Biliary cohe (unassoented with inflammation of
the gall bladder) is distinguished from cholccjstitis
by its more acute onset, more paroxysmal and
agonizing pain, and by the greater accompanying
collapse Theabdommal nail over the gall-bladder
IS soft and yielding, though there may be local
deep tenderness The pam is usually' radiating,
being felt specially m the riglit subscapular area
It may also be felt on the left side, in nliich case
there may be a complaint of a sense of constnction
round the naist Tins feeling of constriction, n lien
present, is \ery characteristic of biliary colic A
subnormal temperature IS more common tlian fc\er,
and transient jaundice is common after the attack
With rapture of the gall-bladder or one of the bile-
ducts there arc usually the Justory and sj mptoins
suggestive of biliary colic or cholecystitis, with a
gradual extension of the painful area downwards
until tlie whole abdomen is tender, distension of
the intestines increases and there is tenderness on
rectal examination Free fluid may sometimes he
demonstrated There is often a history of acute
onset, with a subsequent remission of symptoms
for a day or tw o and a final exacerbation of sy mptoms
as the peritonitis spreads o\cr the abdomen

With retroperitoneal rupture of the bile duct
the symptoms and signs remain localized to tlic
right side of tlic abdomen, and there is sometimes
an irritation of the renal pcUis, causing pam on or

CAUSES OF ACUTE PAIN 193

frequency of micturition. This rare condition is,
however, almost impossible to distinguish from
cholecystitis or appendicitis before operation.

In hepatitis the tenderness is all over the liver,
including the lateral aspect as ascertained by pres-
sure in the lower intercostal spaces laterally, as
well as in the right hypoehondrium. This sign
serves for diagnosis except in those cases where
hepatitis coexists w'itli the cholecystitis.

In right basal pleuro-pneumonia or diaphragmatic
pleurisy fever is usually higher (104® or 105® F.),
there may be an initial rigor, the right hypochon-
driac tenderness is more superficial, and by gradual
coaxing the fingers may be pressed well into the
subhepatic region, and there should be signs — at
any rate fine crepitations — at the base of the right
lung and pleura. Pain on top of the right shoulder
would be much more likely to be met with in
diaphragmatic pleurisy than in cholecystitis. The
occurrence of hemoptysis in any doubtful case would
suggest cither pneumonia or pulmonary infarct.

13

CHAPTER XI\

THE COLICS

True abdominal colic is always ciuscd bj the
violent peristaltic contraction of one of the in
voluntary muscular tubes, nhose normal peristalsis
IS quite painless The Molencc of the contraction
IS usually produced in an effort to o\ crconic some
obstacle which prevents the passage of the uornial
excretion or secretion Hie pam is due to the
stretching or distension of the tube, and the ngon>
produced ma> be as se\ ere as any to w Inch a human
being can be subjected

The in\oluntary muscular tubes which ma} thus
cause colic arc

Tile stomach
Intestines

C}stic, hepatic, and common bile ducts
The ureters

Ihc uterus (and rallopian tube)

The pancreatic duct

The mam features of severe colic are tlic occur
rence of acute agonizing spasmodic pain, whitli
doubles up the patient It is associated in varying
degree with the symptoms consequent on sliock
due to excessive stimulation of tlic sjnipathctic
nervous sjstem, eg pallor or hvidit}, weak pulse,
vomiting, subnormal temperature or coldness of the
191

THK COLICS

195

body-surface. 'The pain is referred partly to the
local site of origin, and partly to the area of nerve
distribution of the segment of the spinal cord wth

Fio 35 — Diagram to show eomnion sites to which pain ta referred In
the various forma of colic (1) hypochondriac (over gall bladder) ;
(2) Bubscapular, painful areas m biliary coho; (3) renal cohe ; (4)
small gut pain ; {5} appendicular colic ; (6) sensitive area in iliao
abscess ; (7) lorge-bowol pam. (See also Fig. 3 on page 11 )

which the affected part is associated. The ab-
dominal muscles, in common with many other of the
voluntary muscles, may remain contracted and rigid

190 DUGNOSIS or THE ACUTE ABDOMEN

during the height of tlie piin, but the^ relax \\Iicn
the spasm of pain subsides, and the fingei*s maj then
be pressed fairlj easilj into the abdominal ca\ itj ,
though there may be local tenderness o\cr tlie
affected \iscus

In the general diagnosis of a colic the lolloning
points may help

(1) In colic the patient is usuallv very restless,
and flings himself about as if to find some relief
from the pain which grips liim A flexed position
of the body ma> be adopted during the pam

(2) In colic pressure to the abdomen sometimes
rehev es the pain — an occurrence not usual in other
acute conditions

(3) The pam usually comes in paroxj sms lasting
a V amble time

(4) Though occastonallj rigid dui ing tlic paroxj sms
the abdominal uall is soft betneen the bouts of
pam In sudden acute peritonitis it remains rigid
all the time

(5) In many of the colics the pnin distribution is
almost diagnostic (Fig 35 )

Intestmal colic— Cohe of the small ^nteshne is
sometimes caused bj catarrhal enteritis due to tlie
irritation of improper food, ptomaine poisoning
or the toxins of some fev ers It is met with m more
sev ere degree m tliat rare condition termed “ cntcro
spasm,” and in cases of organic obstruction to the
small intestine Tlie pam is acute and griping, is
referred to tlie epigastric or umbilical region, and is
accompanied sometimes by local areas of distension
where gurgling sounds maj be licard, and sometimes
felt by the palpating band Vomiting maj take
place, and peristalsis ina> ocensionnilj be seen

THE COLICS

197

through the abdominal wall When due to en-
teritis the pain is gene!rally soon followed by diar-
rhoea, the nature of %\liich may give the clue to the
cause of the pain \\nien due to organic obstruc
tion the attacks v ill occur from time to time till a
final attack of acute intestinal obstruction occurs
Enterospasm cannot well be distinguished from
organic obstruction I\Ticn pain, assumed to be
due to intestinal colic, persists for more than tlirce
oi four hours, the condition is generally one needing
surgical interv ention

Lead coltc is a form of colic of the small intestine
vhich IS accompanied by constipation The pain
may be extreme and the collapse of tlic patient
severe During the spasms of pam the abdominal
wall may be rigid Otlicrsigns and symptoms point-
ing to lead poisoning (blue line on gums, severe
constipation, local paralysis, etc ) may be present,
and the patient’s occupation is usually that of a
painter, or one who comes in contact with paint

Colic of the large intestine is very frequent, but
the pain occasioned m the large boi\e! is seldom so
acute or prostrating as tint resulting from colic of
the small bo>\el The pain is referred chiefly to the
hypogastnum The causes are either severe cons-
tipation, due to hard sc> bnlous masses, colitis or d> s-
entery, or some form of stricture of the large boiiel
Pam m the colon is often more accurately localized
by the patjfjot tJiaio js the pam rtf smaJJ-boweJ ccOjc,

Diagnosis. — In any case of intestinal colic
diagnosis is greatly aided by the history, for tlie
historj of eating of tainted food, the occurrence of
previous similar attacks in one who is a painter by
trade, or an account giv en of former bouts of d j sen

198 DIAGNOSIS OF THE ACUTE ABDOMEN

tery, may thro^v considerable light on the problem
By obtaining a careful history it should also be pos
sible to exclude appendicular colic The occurrence
of diarrhoea would usually exclude intestinal ob
struction, but it must be recollected that loose
motions are sometimes seen w itli an intussusception
(qi ) Local or diffuse peritonitis must be excluded
by noting the absence of ngiditj uhen the seicrc
pain subsides, the relief obtained bj gentle pressure
on the abdomen, and the absence of tenderness
of the peUic peritoneum
If attacks of small intestine colic recur from time
to time and lead to loss of neight, tlie possibility of
organic obstruction (by adhesions bands, tuber
culous stricture or neoplasm) must be considered,
nor IS it nisc to delay too long before nd\ising
exploratory operation lladiogrnpliic ckamination
of the intestinal tract after administering an opaque
meal Mould help in diagnosis Tuberculous mesen
tenc glands frequently lead to subacute attacks
of intestinal colic and in these cases a radiogram
may sIiom CMdencc of calcification of tlic glands
Similarly Mhen there are recurrent attacks of
distension of the large bowel, accompanied by colic
and constipation, it is wise to suspect carcinoma or
stricture of the colon or rectum, and certainty on
the question must be obtained by the proper ding
nostic procedure (see Chapter IX)

Bibary colic is caused by the passing of a stone
or inspissated bile through tlic cystic, hepatic, or
common bile ducts It aanes considerably m
intensity according to the diHiculty winch the stone
experiences in trasersing the ducts Tlie pam is
usually sudden m onset and severe m intensity

THE COLICS

190

Vomiting IS common and collapse may be so severe
that the observer may consider the patient %n
extremis Occasionally death has actually occurred
during an attack of biliary colic, and the writer has
kno^vn one such case, but fortunately this event is
exceedingly rare Generally the patient n rithes in
agony, but in the worst cases may he still with
pmehed, blue face, cold cxtiemities, and weak pulse
The pain is felt

(1) In the right hypochondrium, ^\hlch is
usually tender on pressure

(2) Below the inferior angle of the right
scapula

(3) Occasionally at the same levels on the
other side of the body

(4) Infrequently it may be referred to the
right acromial and lo^sc^ cervical region

The common position of the pam corresponds to
the distribution of the nerves from the eighth and
ninth dorsal segment of the spinal cord

Jaundice is not a necessary accompaniment of
biliary colic, but in slight degree it is a frequent
sequel

Diagnosis is usually fairly clear on account of the
intensity and distribution of the pain and the
absence of local abdominal rigidity when the pam
passes off When ngidity persists in the right
hypochondrium there must be accompanying
cAofecystifis or iocai peniant^is it fcaAing or
inflamed duodenal ulcer causes also persistent
rigidity , but in the case of ulcer there should be a
definite history suggestive of tlmt condition (sec
Chapter XIII)

Renal cohe is caused by the passage of a small

200 DIAGNOSIS OF THE ACUTE ABDOMEN

stone, a portion of blood-clot or inspissated pus,
oxalate crystals or uratic debris clown the ureter,
by the impaction of a stone in the renal pelvis, and
sometimes by sudden kinking of the uretero-pchde
junction when there is an unduly mobile kidney.
It is sometimes, but by no means always, accom-
panied by heematuria.

The symptoms arc usually characteristic. The
patient is seized with sudden pain starting in the
loin and often radiating to tlic corresponding testicle
or groin, or, (in w’omen), to the vulva. In some eases
there is extensive superficial hyperesthesia of the
abdominal wall either in front or posteriorly. In
severe cases there is violent restlessness. Vomiting
is common. There may be frequency of urination
and pain on performing the act. Ilccmaturia may
accompany or follow the pain. Renal colic in males
by no means always radiates to the testicle, and it
must be remembered that pain due to inflominatlon
of the appendix is sometimes felt in tlic testicle.

Diagnosis . — Tlie distribution of tlic pain is
characteristic, and local examination of the loin
may reveal a tender and possibly enlarged kidney.
An X-ray examination may show a stone to be
present, but there are many cases of renal colic in
^Yhich no stone is seen by the X-rays, yet a small
stone is passed later. Minor degrees of ureteric
colic arc frequently misdiagnosed appendicular
colic, especially ivhcn an X-ray photo is unsuccess-
ful in revealing the small calculus.

TTterine colic. — Dysmmorrhosa . — TIic pain caused
by the uterus in its attempt to expel cither a foetus,
a polypus, a membranous cast, or even blood-clot
may be very severe. Tlic pain is referred cJiicfiy

TXIE COLICS

201

to the lower lumbar region> but in severe cases it
may radiate down the tliighs and over the hips.
V^omiting and retching may occur.

Spasmodic dysmenorrhoea may cause the patient
to writlie. Since witli any abdominal pain in women
the menstrual history would be inquired into, and
with spasmodic dysmenorrhoea vaginal and pelvic
examination would show no special reason for pain
of a uterine origin (apart perhaps from a pin-hole
os and small cerv'ix), tJierc sliould be little diUiculty
in diagnosis.

Gastric colic. — Attacks of severe epigastric pain
of a colicky nature sometimes occur in those who
arc the subject of pyloric stenosis, due to ulcer or
neoplasm. In such cases the peristaltic wave can
often be seen going from left to right, and the out-
line of the dilated stomach may readily be recog-
nized through tlie abdominal wall. The pain is
referred to the area of distribution of the tenth
dorsal segment, chiefly on the left side. Severe pain
may also be caused by a sudden haemorrhage taking
place into the stomach. In such cases there is
usually a history suggestive of gastric ulcer. The
severe pain and collapse and epigastric tenderness
may lead one to diagnose intestinal obstruction or
gastric perforation. But the sudden antemia and
tiie vomiting of altered blood (which usually occurs)
will give the clue to the correct diagnosis.

Pancreatic colic. — ^^cry occasionally obstruction to
the duct of Wirsung may give rise to colic. Severe
pain, sometimes radiating to the left shoulder, may
be felt, and there will be symptoms of pancreatic
derangement, but the condition is probably rarely
correctly diagnosed before operation.

CHAPTER XV

THE EARLY DIAGNOSIS OF ABDOMINAL
INJURIES *

Evehy case of abdominal injury which is obviously
of a serious nature is nowadays removed to the
care of the surgeon ; but since tliere arc many
cases in which, though serious injury lias resulted
from the injury, the symptoms are not obvioxis and
indeed may remain latent for some hours, it is
useful to summarize the main points in diagnosis.

We shall confine ourselves to the consideration
of those injuries in which tliere is no open wound
of the parictes, for when a stab or penetrating wound
of the abdominal wall exists tliere should be no
question that the treatment is surgical.

Non-penetrating injuries of the abdomen arc
most commonly due to severe cruslics, ns would
follow from a heavy vehicle running ' over the
abdomen. Another type of violence is the sharp
circumscribed blow due to a kick, punch, or the
sudden impinging of any hard body against the
abdominal wall. Severe injury may also follow
the strain on the viscwal attachments consequent
on a fall from a Iieight, or a sudden trip-up causing
a violent fall forward. When violence is applied

• Tlic author indcbtc'l to the publishers of The Dictionary oj
Practical Medicine for permission to abstract from ids article in Unit
publication.

20.:

ABDOMINAL INJURIES

203

against the abdominal wall the kind of injury
produced depends to a certain extent upon the
preparedness of the patient for the blow and the
consequent rigidity or flaccidity of tlie abdominal
muscles. If the muscle is taken unawares more
serious intra-abdominal mischief is to be expected,
whereas if the muscle be rigid it may mitigate or
prevent injury of the underlying viscera.

Any injury of the abdominal wall, however
slight, may be accompanied by serious lesions of
the viscera, and the latter may be seriously injured
without any visible sign of injury to the abdominal
irah. When there is no external wound the thought
of visceral injury may not be present in the mind,
and grave lesions may be allowed to progress con-
siderably before they are noticed.

The solid viscera of tlic abdomen (liver, spleen,
pancreas, kidneys) are situated high up in the
abdomen largely under cover of the ribs ; the hollow
tubes (intestines, bladder, ureter, and stomach) arc
more exposed to injury.

Injury to solid viscera causes hromorrhage, injury
to the hollow viscera usually causes peritonitis,
whilst both types of lesion are accompanied by shock.

Shock is shown by, pallor, feeble pulse, sweating,
slow shallow respiration, and cold extremities, but
unless there is some serious lesion the symptoms
soon subside. If the state of shock lasts longer
and seems out of proportion to the evidence of
intra-abdominal injury, examination may reveal
a pneumothorax or other clicst-lcsion. Injuries of
the upper abdomen cause more serious shock than
those of the hypogastric r(^ion. Renal contusions
also cause severe shock.

204 DIAGNOSIS or THE ACUTE ABDOMEN

If the symptoms of shock do not pass off within
SIX hours, h'cmorrh'igc or peritonitis is almost
certainly an additional factor

Owing to the anatomical disposition of the parts
hsemoirhage usually follows lesions of the upper
zone in which lie the li\er and spleen The mam
abdommal vessels arc more Ukelv to be injured by
violence directed against the central portion of tlie
abdomen MHien the liver or spleen is severelj
torn, the symptoms of shock and hicmorrlngc are
extreme, and death frequently follows soon after
the injury In lesser degrees of injury of the solid
viscera (or of the mesenteric blood vessels) e\ idences
of bleeding gradually assert themselves Increasing
restlessness, and pain, progressive pallor of tlie hps
and finger nails, a rising pulse rate, and the demon
stration of movable dullness m the flanks arc siifTi
cicntly indicative Occasionally tlic symptoms of
haimorrhage may abate for a day or two, and then
become alarmingly evident after some exertion,
e g straining on the bed pan Tins is more likely
to occur after injuries to the spleen The pulse rate
is a good but by no means infallible guide m ob
dominal Iiaimorrhagc It may continue fairly slow
(not above 100) till the abdomen is full of blood,
and then suddenly bound up to a rapid rate
Presumably the increase m rate takes place wlicn
the cardiovascular compensating mechanism fails

Cout'-mow or ruptorc o/ Lvlucy is Cccqucatly
accompanied by very severe and alarming shock,
which generally passes oft within an hour or two
(cp the “ kidney punch ” in boxing) The later
symptoms depend on the extent of the injury and
the condition of tlic renal capsule In slight cases

ABDOMINAL INJURIES 205

where the capsule remains intact, hcematurm, local
tenderness, and sometimes renal colic due to the
passage of clots doum tlie ureter, comprise ail the
symptoms. If the renal capsule be torn a retro-
peritoneal liECmatoma is formed, and sometimes urine
IS extravasated into the cellular tissues behind and
around the kidney , this leads to cellulitis accom
panied by malaise, irregular fever, and local swell
mg, tenderness, and muscular resistance. An
abscess may result. If the urmc be infected the
symptoms are more acute. Should the peritoneal
covering of the kidney be torn, symptoms of mtra-
peritoneal liiemorrhage will result Most cases of
liosmaturia resulting from renal contusion stop
spontaneously

Peritonitis is usually consequent on rupture of
the hollow viscera The intestines, bladder, and
stomach are most commonly injured, tlie gall-
bladder and ureter rarely. Sometimes the injury
IS only sufficient to bruise the waDs of the viscus
If the stomach be thus contused the result is
vomiting and sometimes hiematemesis ; if the colon
be bruised the passage of blood per anum and
diarrhoea due to traumatic colitis may follow

Bruising of the bladder causes slight lucmaturia,
but if the contusion be severe there may be vomit-
ing and local muscular rigidity, even though no
rupture has occurred.

Rupture of intestine ‘ is the commonest cause of
peritonitis after abdomuial injury , it is a condi
tion fraught with danger of almost certain death if
not diagnosed early, yet the signs and symptoms

* I'ldf Cope “ Tlie Rarly Diagnosis and Treatment of Uiiptured
Intestines ” Procetdings oj Royal Society of Medtcine, 1014

20G DIAGNOSIS OF THE ACUTE ABDOJfEN

are often equivocal for some hours. Genenilly the
tear only involves a portion of the circumference
of the gut, but occasionally a complete severance
is caused and a gap left betAveen the two ends whicli
may be temporarily dosed by contraction of the
involuntary intestinal muscle, ^^^len intestine is
injured its peristaltic movements stop oAving to a
reflex or direct paresis of its Avails. If the rent be
small the edges of the mucous membrane pout and
fill the small gap ; a small, amount of intestinal
contents escapes and sets up a local plastic periton-
itis with deposit of lymph which glues togetlmr the
coils of intestine. The patient takes nothing by
the mouth, and the gut remains at rest. A lull in
the symptoms gives a false security. After n fcAv
hours, Avhen tlic obsen'er may Imve decided that
there is no serious intra-abdominal lesion, food is
taken, the intestines arc excited to peristaltic
contraction and the opening in tlie gut is unsealed.
Peritonitis tlicn develops more or less rapidly
according to the size of the opening and tlic number
of adhesions.

Tile important earlier signs of peritonitis are :

Pain.

Local tenderness.

Local muscular rigidity.

Vomiting.

Sliallow abdominal respiration.

Tiie later evidences of peritoneal infection arc :

ElcA'ation of pulse and temperature.

Increasing distension.

Tenderness of pelvic peritoneum.

Movable dullness in the flanks.

ABDOMINAL INJURIES 207

Obliteration or diminution of liver-dullness
(caused by gas in front of the liver).

The patient often has an anxious facial expression
and may show unusual restlessness. In injuries of
the upper abdomen importance must be attached
to the shifting of the pain to the hypogastrium,
due to the inflammation caused by the escaped
intestinal contents which gravitate to the pelvis.

A plain X-ray photograph of tlie abdomen may
be useful by showing free gas localized near a rup-
tured portion of gut.

The prognosis in cases of ruptured intestine is
very bad, unless diagnosis is made and operation
undertaken soon after the injury. Ilencc the need
for early diagnosis.

Provided there be no lesion in the chest, and tliat
renal trauma can be excluded, one is probably
dealing with a ease of ruptured intestine in the
following conditions :

(1) When severe abdominal pain persists for
more than about six hours after an injury, if the
pain be accompanied by either (a) v'omiting,
especially bilious vomiting ; or {b) a pulse gradually
rising from the normal ; or (c) persistent local
rigidity tending to extend ; or (d) deep local tender-
ness with shallow respiration.

(2) abdominsti pain is absent or very
slight, and anaemia is not increasing, but the pulse
rises steadily hour by hour, and the patient is very
restless or listless.

When marked diminution of the liver-dullness
occurs with any of the above symptoms, or if there
be signs of free fluid in the abdomen or rectal

208 DIAGNOSIS OF THE ACUTE ABDOMEN

examination sho^\s the pehic pentoneiirn to be
xer> tender, the mdications for operation ^^ollld
be imperati\ c.

It IS assumed that the opening of the abdomen
nould be adxised ^^lthout any dcla> if the symp-
toms of peritonitis iiere quite typical.

It IS possible for tlie duodenum and parts of the
colon to be ruptured behind the peritoneum. The
symptoms are then due to a retro peritoneal cellu
Iitis, aitli some inflammation of the contiguous
peritoneum, xiz local pam and muscular rigiditj,
shalloiN respiration, vomiting, rise of pulse rate
and of temperature In a case of retroperitoneal
injury to tlie auodenum which was under my care
the pam at first Mas \cry slight but became greater
hour by hour till I felt constrained to open the
abdomen tliougli there Mere feu local signs to guide
one, A very important diagnostic sign (Mhen
present) is surgical cmphjscma of the rctropen
toneal tissues.

Rupture of the urinary bladder usually occurs
m connexion with fractured pel\is, but may re-
sult from a bloM on the Iiypogastnum Mhen the
viscus is distended. In children the bladder is
situated higher up in the abdomen, and is tlicrcfore
more liable to injury. The symptoms \ ary accord-
ing ns tlie rent is mtra- or extra peritoneal. If
within the peritoneal ca\nty, symptoms of peritoni-
tis ensue, but it must be remembered that sterile
urine docs not at first cause a x cry acute infiam
matory reaction. There may be hmm.'ituna

Rupture outside the peritoneum tends to ex-
travasation of urine and conscquait ccllnhtis in
the suprapubic and pcrmcal regions.

ABDOailNAL INJURIES 200

In a child with fractured pelvis the membranous
urethra may be tom completely across, and the
neck of the bladder ^^ith the torn portion of attached
urethra may retract from the triangular ligament.
In. such cases the bladder-sphincter may remain
closed and the viscus become over-distended.
A tense and tender swelling will thus be detectable
in the hypogastrium. The tenseness and tender-
ness of the lower abdomen thus produced may cause
the diagnosis of peritonitis to be made erroneously.

Rupture of the stomach quickly leads to
symptoms of general peritonitis ; it is generally
accompanied by some other lesion such as injury to
the spleen or liver. The part of the stomacli likely
to be ruptured by injury is that part which is
seldom the site of ruptured ulcer, i.e. the greater
curvature. The gas wliich escapes may for a time
be localized and form an area of superficial
tympanitic resonance on percussion.

The pancreas is rarely injured, and the symptoms
of such injury are in no way distinctive. Shock is
always great.

Diagnosis of abdominal iniuries. — The essential
point in diagnosis is to estimate the different pro-
portions which shock, htcmorrhagc, and peritonitis
take in tlie production of tlic observed symptoms,
and to judge from this the viscus injured and the
nature of the lesion.

ft IS frequentfy impossibfe to give a cfehnitc
opinion for a few hours after the accident. Initial
shock usually subsides witliin two or tlirec hours,
and then symptoms of iiajmorrhage or peritonitis
become increasingly evident. If shock is still
present after tliree hours there is nearly always
14

210 DIAGNOSIS OF THE ACUTE ABDOMEN

some serious visceral lesion. Pain, vomiting, local
or general muscular rigidity, tenderness, alteration
of pulse-rate, shallow respiration, diminution of
liver-dullness, free fluid in the abdomen — these are
the main symptoms to note. By taking into con-
sideration the part of the abdomen struck, it is
possible in many cases to say which \'iscus is iiijurcd
and what is tlie nature of the injury.

In cases of suspected rupture of the bladder two
additional means of diagnosis are available i

(1) The bladder is emptied by a catheter and n
measured quantity of boric acid or saline solution
is introduced and again dra^vn oil. Any serious
discrepancy between the amount put in and drawn
out suggests rupture of the bladder.

(2) Cystoscopy may show' a rent in tlic bladder,
but this should only be carried out by an expert
in the use of the cystoscope.

Differential diagnosis . — It is very important
always to examine the thorax carefully for
pneumothorax or Iiasmopneumothorax. Symp-
toms very suggestive of serious abdominal injury
may be produced by cither of these lesions. Ab-
dominal pain and rigidity and the general signs
of shock and hajmorrhage may follow a fracture of
rib W'ith rupture of lung and consequent presence
of blood and air in the pleural cavity. Hence the
need of careful thoracic examination. In cases of
doubt radiograpljy of the chest, by means of a
portable X-ray apparatus, would clearly show
whether there were a pneumothorax.

CHAPTER XVI

THE ACUTE ABDOMEN IN THE TROPICS ^

In tropical climes tliere are several common acute
abdominal conditions which are seldom seen in
temperate regions. For the most part these are
the manifestations of malaria and dysentery. Some
of the most common are :

Hepatitis (amoebic or malaiial).

Acute liver-absccss.

Rupture of Uvcr-abscess.

Dysenteric typlilitis.

Acute or subacute dysenteric perforation.

Perforation of a typhoidal ulcer.

Pain in the right upper quadrant of the abdomen
which in temperate climes usually indicates chole-
cystitis or duodenal ulcer, in the tropics frequently
means either amoebic or malarial hepatitis.

AMCEBIC HEFAimS

It is essential for the practitioner in the tropics
to liave a sound knowdedge of the symptoms of
amoebic hepatitis, since it is the first stage toward
amoebic abscess of the liver, and prompt and early
recognition and treatment of tlie hepatitis will save

‘ See Tht Surgical Aspects of Dysentery, Ly Zaclnry Cope (Henry
Frowde and llodder & Stoughton).

211

212 DIAGNOSIS OF THE ACUTE ABDO'NIEN

many a patient from the incon\ cnience and danger
of surgical interference.

Hepatitis may develop during the course of an
acute amoebic colitis, or it may come on at a period
remote from the djsentcnc attack. TIic amcebT}
travel to the liver via the radicles of the portal
vein, and lodging m the portal capillaries cause
extensive inflammation

Symptojns . — ^Tliere arc five constant features
and many inconstant symptoms to be looi.ed for in
amoebic hepatitis. The constant featmes arc:

^(1) Enlargement of the liver,

J[2) Pain and tenderness in the hep itic icgion.
^(3) Fever.

Leucocjtosis

s^(5) Reaction to emetine.

The common though inconstant features are .

Ilistorj of dysenlcrj.

Jaundice.

Pam in the right slioulder region, or in iliac
region.

A rigor.

Lassitude and malaise.

Foul tongue.

Sv\ eating.

The occurrence of fever, vvitli an enlarged painful
liver, m a person vvlio is or has been living in a
trojneal country’ should always lead one to suspect
amccbic hepatitis, whether there is a definite
history or not of amccbic dysentery The occur-
rence of Icucocy tosis (15,000 to 20,000) is corrobom*

ACUTE ABDOMEN IN THE TROPICS 213

tive evidence The presence of any of the incon-
stant symptoms may be taken as confirmation
The diagnosis is always clinched by the rapid, often
dramatically rapid, subsidence of symptoms under
treatment by hypodermic injection of emetine
hydrochloride one gram daily for ten dajs The
symptoms begin to abate after the administration
of two or three doses

Dijfcrenhal diagnos%s — There arc several pitfalls
that he in wait for the unwaij Malaria may
cause a hepatitis with jaundice This can be e\
eluded by examining the blood for the malarial
parasite Cholecystitis may be wrongly diagnosed
because the pain may be most evident m the gall-
bladder region If the pain be also referred to the
right iliac region, there is a simulation of appendi-
citis In a tropical country it would be a wise
procedure for the smgeon to tiy tlie effect of a
short course of emetine before operating on any
but the most fulminating types of appendicitis and
cholecystitis

Acute pain m the right lower quadrant of the
abdomen when occurring in a patient residing m a
temperate clime is usually due to appendicitis
In the tropics, Iiowcver, one must also consider
{in addition to hepatitis)

Dysenteric typhlitis

Cfccal perforation with local abscess

Leaking hepatic abscess

Tiie insidious nature of amoebic colitis permits
considerable pathological lesions to exist w ithout
many symptoms Ulceration in the caecum is

21 i DIAGNOSIS OF THE ACUTE ABDOMEN

frequently accompanied b> considerable swelling of
the gut, but ma\ be unaccompanied bj nn> djsen-
tcnc s} mptonis — on the contrari , constipation ma\
be the complaint If then, in such a case, pam is
suddenly complained of in the riglit iliac fossa,
the temperature becomes delated and lomiting
occurs, and on cvammation a tender lump is found
in the appendicular region, the conditions for a false
diagnosis arc ciident. The surgeon practising in
the tropics must not be too ready to operate on
painful suellings m the right iliac fossa. Ihc
examination of the faices for amcebT, and the trial
of treatment bj emetine for tuo or three dajs, arc
useful and often ncccssarj prchmmaiy’ procedures,
for operation on cases of amoebic typhlitis is fraught
Mith peril

Perforation of the caicum may take place in-
sidiousl) , and adlicsions may limit infection to the
iliac fossa Such eases, apart from the historj,
arc almost indistinguishable from those of ap-
pendicular abscess.

Since local abscess mil alwnjs need to be opened,
the actual mistake as to the cause of tlie abscess
makes little difference saic that more rapid healing
mil ensue if emetine is simultancouslj given in
cases of anucbic djscntcr^.

Simulation of appendicitis bj a leaking hepatic
abscess IS a rare event, but an instance has conic
under mj observation.

General abdominal pain ma> be produced in the
tropics bj tlic usual causes described in tlic different
chapters of this book, but m addition one maj
hav c to deal mth .

ACUTE ABDOMEN IN THE TROPICS 215

Rupture of liver abscess into the general
peritoneal cavity.

Rupture of dysenteric ulcer.

Rupture of typhoidal ulcer.

Cholera sicca

Ruptured spleen

Rupture o! liver-ahscess into the general peritoneal
cavity IS not common, but is sufTiciently frequent
to bear in mind as a possible cause of the acute
abdomen It would give rise to all the symptoms
of diffuse peritonitis (q v ), and unless the patient
was kno^vn to have been suffering from recent
liver diseases it is unlikely that the proper diagnosis
would be made before the abdomen uas opened.

Rupture of dysentenc ulcer into peritoneal cavity.
— ^The most common sites for perforation are the
cseeum and sigmoid colon Consideration of the
grades of acuteness of the amcebic ulceration will
explain partly tlie difference ot symptoms which
may result after perforation In the acute type of
inflammation, in which masses of the mucous mem-
brane are cast off as gangrenous sloughs, tliere is
little reaction in the bowel wall, and ulceration
may penetrate througli to the peritoneal coat before
time has been allowed for protective adhesions to
form In such cases, when the bowel finally gives
way, the peritoneal cavity may suddenly be flooded
with fffical material and fatal general peritonitis
rapidly ensue.

If, Iiowe\ er, the ulcer is subacute and the wall of
the colon only permits a gradual erosion, there may
be time for omentum or intestine to ndlicre to the
peritoneum covering the base of the ulcer. Ad-

21C DIAGNOSIS OF TIIE ACUTE ABDOJIEN

hesions may therefore prevent the rupture, or maj
surround the diseased area so that, ^\hen nipturc
takes place, tiie escape of gut contents is into a
limited space A localized abscess then results

Tliere is an intermediate tjpe of lesion in Avhich
perforation niaj not occur, but an escape of organ-
isms maj take place through the thinned ulcei-base
into tlie peritoneal ca\ity, though there is no general
escape of intestinal contents, and the base of the
perforating ulcer is \ crj soon sealed up bj adhesions

The si/mptoms produced b) perforation in a case
of djscntcrj ntll ^ar\ in seventy according to
pathological type

(a) If fjccal flooding of the general pcritoncnl
cavity occurs, the sjmptoins indicating the catas-
trophe will be an onset or increase of abdominal
pain, \ omiting, collapse, rising pulse rate, distension,
and abdominal wall rigidit) In patients who arc
exhausted by the djscntcric condition, and m
wliom abdominal pam and distension hive been
considerable, rigidity ma^ not be a marked feature,
and the exacerbation of svmjitoms maj not casih
be distinguished from the collapse of sev ere toxicmia

(b) If the leakage is gradual, and ndlicsions occur,
the signs of local abscess will develop

(c) In the intermediate tape the symptoms will
be those of subacute peritonitis

Rupture of a typhoid ulcer mnj occur in some
cases of ambulatorj typlioid fev cr, so tlint a person
previouslv supposed to be m fair hcnlth ina> be
brought in with symptoms of peritonitis of recent
origin Tiie symptoms wouhl at first be more
evident in the lower abdomen, since it is usually in
the ilciim that the perforation occurs. Unless there

ACUTE ABDOMEN IN THE TROPICS 2lT

were a history suggestive of the onset of typhoid
fever it is unlikely that the condition vould be dis-
tinguished from appendicitis with pelvic peritonitis
Rupture of spleen, — In tropical and subtropical
countries where malaria is endemic there are many
of the population who have enlarged spleens
Slight trauma may occasionally^ cause rupture of
such an enlarged spleen, and very rarely rupture
may occur spontaneously
The symptoms vould be collapse and the signs
of internal haemorrhage The only hope of cuic
would be by operation to remove the spleen

Cholera szcca, — Tiierc are some cases of cholera
in which the patient is seized witJi violent abdom-
inal pains and symptoms of very severe toxxmia,
which may cause death before the stools have be-
come frequent and characteristic Such an acute
condition might possibly simulate other forms of
.the acute abdomen, but the absence of abdominal
rigidity and the seventy of the to\ncmia would put
one on guard, and the prevalence of cholera would
make one suspect the true cause Moreover, in
cholera sicca tliere is no rallying from the initial
collapse If the patient live long enough the charac-
teristic stools would appear and clinch the diagnosis.

Heat-stroke. — In very hot seasons and in places
where a number of heat strokes are occurring it is
well to remember that the initial stage of some
cases of heat stroke may’ shovi gastro intestinal
symptoms It is \ ery scldonx, how ever, that there
could be any mistaking these symptoms for an
acute abdominal disease, for there arc always other
symptoms — dry skin, hyperpyrexia, mental dull-
ness, etc — which would guide one correctly’.

CHAPTER XVll

ACUTE ABDOMINAL DISEASE WITH GENITO-
URINARY SYMPTOMS

Acute abdominal disease with gcnito ininar^
symptoms may be due to primary disease of the
gcnito urinary organs, or to secondary irritition of
those organs consequent on disease of otlicr viscera
The mam symptoms which maj call attention arc

(1) Painful swelling in tlie position of tlie
kidney

(2) Renal colic

(3) Disorders of micturition — pain, fre-
quency, retention

(4) Abnormalities of unne— liainiaturia, al-
buminuria

(5) Pam in testicle or along spermatic cord

(0) Tenderness at the right erector costal

angle

(1) A pyonephrosis or a hydronephrosis may gi\c
rise to acute symptoms In cacli case there will be
found a rounded tender swelling m the loin Tiie
tumour will be felt to fill out the posterior lumbar
region The colon may be felt to the front and
inner aspect of the swelling, but if the lom is well
filled by the tumour that alone is usually quite
sufTicicnt to diagnose a renal swelling In boUi
pyonephrosis and liydroncphrosis there should l>c
a history of prc\ious urinary trouble Acute
attacks of pain arc prone to occur in a recurring

GENITO-URINARY SYMPTOl^tS 219

hydronephrosis, and gastro-intestinal symptoms
(flatulence and vomiting) may accompany the
attacks If seen during an attack, however, the
swelling IS characteristic. In a pyonephrosis there
are usually the signs of toxic absorption — fever,
furred tongue, and a toxaemic appearance. With
a hydronephrosis the symptoms are less severe.
Sometimes it is difficult to obtain a history of
icnal symptoms, and then it may be impossible by
chmcal examination to diagnose a pyonephrosis
uith accompanying perinephritis from other causes
of local suppuration such as appendicitis or divcr-
ficuhtis — particularly in a fat patient

Polycystic disease of the kidneys may give rise
to uraemia with vomitmg and abdominal distension.
This might be mistaken for intestinal obstruction,
but the presence of tumours in both loins v ould make
one suspicious, and the occurrence of albuminuria
and high blood-pressure would make the diagnosis
almost certain. A polycjstic kidney usually has an
irrcgulai surface due to the smooth cysts which
^ary considerably m size

(2) Pam of the type of renal colic may be caused by ;

Stone in pelvis of kidney.

Stone in ureter.

Blood clot or umtic debris in ureter.

Dietl’s crisis.

Appendicitis.

In icnal colic the pain starts m the loin and
frequently radiates to tlic corresponding testicle.
It may be due to anything solid or senn-sohd
passing dowm the ureter, or to a sudden kink in
the ureter due to a movable kidney (Dictl’s crisis).

220 DIAGNOSIS OF THE ACUTE ABDOMEN

There is usually no difficulty in diagnosis, though
occasionally appendicitis may cause pain of n
similar nature. But in appendicitis severe enough
to cause the simulation of renal colic there ^viU
usually be persistent local muscular rigidity, which
is not usually found in renal colic. (Sec Chap. XIV.)

(3) rain on or frequency of urination is found in
nearly all cases of pyelitis, and in many cases of
renal colic, but it is often also noted in appendicitis
and other causes of pelvic peritonitis. Examination
of the urine will prove or disprove a pyelitis.

In appendicitis pain on, or a frequency of, urina-
tion may be due to irritation of the renal pelvis,
ureter, or bladder by the inflamed appcndi.x or con-
tiguous peritonitis. When this symptom is accom-
panied by pelvic tenderness, or a tender Jump felt
per rectum, or a positive obturator-test, the appen-
dix will usually be found in the pelvis irritating the
bladder. Ulicn unaccompanied by tlic other signs
the appendix is generally citlicr near the kidney or
at the pelvic brim.

In pelvic Iioimatocclc due to a ruptured ectopic
gestation there arc frequently urinary symptoms.
Sometimes tl\crc is retention of urine, sou\climcs
slight pain or frequency. In a very anicmic
woman with abdominal pain and urinary symptoms
it is well to think of ectopic gestation.

(4) IIa:inaUtria frequently follows renal colic,
and may sometimes enable one to trace to its
source a renal pain that was not quite typical.

Albuminuria is an exceedingly important symp-
tom, for uraimic symptoms may vco' closely simu-
late intestinal obstruction, and it may only be by
the discovery of albuininurb that one is put on the

GENITO-URINARY SYi\IPTO]MS 221

riglit track. Many patients with nephritis have
undergone abdominal section because of neglect
to test the urine. Toxic albuminuria is found in
many septic states of the abdomen, but it is usually
not difficult to judge when the toxeemia is severe
enough to produce that symptom.

(5) Pain in the testicle is met witli in renal colic
and in a few cases of appendicitis. In the latter
instance it may either be due to irritation of the
sympathetic branch which accompanies the sper-
matic artery, or be a true referred segmental pain
across the tenth spinal segment.

Torsion of the imperfectly descended testicle may
cause extreme pain in the inguinal region. Vomit-
ing occurs and shock may be severe. TJie pain has
the usual sickening character of testicular pain.
The absence of the testicle from the same side of
the scrotum will be noted and make diagnosis easy.

Thrombosis or suppurative phlebitis of the veins of
the spermatic cord causes pain in the inguinal region
and sometimes the iliac region of the abdomen. But
the swelling and painful area extend right down
to the testicle, which becomes swollen and painful.

Abdominal pain may be caused by acute distension
of the bladder, but in such cases there would be
retention of urine or overflow incontinence.

Retraction of the testicle is occasionally noted in
cases of appcoidir-itis. It is due to reflex contraction
of the cremaster muscle.

(C) Tenderness on pressure at the right erector- •
costal angle {i.e. the usual position for eliciting
tenderness of the right kidney) is noted in many
cases of appendicitis, especially when the appendix
is retrociecal in position.

222 DIAGNOSIS OF THE ACUTE ABDOMEN

jRenal symptoms may be caused by any retro-
peritoneal lesion in the region of the renal pelvis ;
thus a duodenal ulcer leaking posteriorly or a
retro-peritoneal perforation of the common bile-duct
may cause frequency of micturition or even slfgiit
hrematuria.

CHAPTER XYIII

THE DIAGNOSIS OF ACUTE PERITONITIS

Apart from htemorrliage, the cause of death in
nearly all fatal acute abdominal cases is either
peritonitis, or acute paralytic or mechanical ob-
struction of the intestines. Spreading or general
peritonitis, with consequent toxfemia and secondary
shock, is the commonest single cause of death.
Nearly all such cases, unless the patient is actually
moribund, demand an opening of the abdomen for
drainage purposes, and it is sometimes impossible
to determine the actual cause of the peritonitis,
cither before the operation or even during its per-
formance, if the state of the patient forbids any
prolonged manipulation.

Infective organisms may reach the peritoneum :

(1) Through a wound of the abdominal wall.

(2) Via the blood-stream.

‘ (3) From the viscera contained within the

abdomen.

(4) Rarely through the diaphragm or by
lymphatic extension irom the t/ngfi.

Tlio only commonly blood-bomc organism of
importance is the pneumococcus, which may cause
severe so-called primarj' peritonitis.

Organisms may reach the peritoneum from the

22-t DIAGNOSIS OF THE ACUTE ABDOMEN

contained viscera either by (a) rupture of a viscus
or (6) by escape through diseased vail of any
viscus. In the female there is the additional patli
of infection via the Fallopian tube. Frequently
a local abscess may form cither extia* or intra-
peritoneally near the diseased viscus, and later
such abscess may burst into the general peritoneal
cavity.

The common causes of general peritonitis arc the
conditions already described in previous cliapters,
and comprise disease or rupture of the liollow vis-
cera, and ruptured abscess of the solid viscera.

Perforation of the appendix vermiformis.

Perforation of gastric or duodenal ulcer.

Perforation of typhoid or tuberculotis ulcer
of small intestine.

Perforation of dysenteric or stercoral \dccr or
of a diverticulum of the colon.

Perforation of goll-bladder, or biliary duels.

Gangrene of any strangled coil of gut, or
intussusception, or volvulus.

Infection spreading from a pyosalpinx.

Infection spreading from nn infected uterus.

Infection spreading from a pyonephrosis.

Rupture of a livcr-absccss or splenic
abscess.

The above comprise all the common causes of
general peritonitis. The symptoms of peritonitis
vary greatly according to the part and extent of
the peritoneum involved, the nature of tlic infective
agent, and the acuteness of onset. Help in diagnosis
will be obtained by rcganling the syinplotns ns

ACUTE PERITONITIS 225

being roughly grouped in two classes — reflex niul
toxic
Pam

Vomiting

Anxious facial expression
Rigidity of abdominal muscles
Superficial hyperaesthesia
Collapse Alteration of temperature
Distension
Intestinal paresis
General toxiemia

The importance m recognizing these two groups
of symptoms lies in the facts that reflex symptoms
are earlier m onset when a demonstrati\ e part of
the peritoneum is affected, but may be delated
considerably when a non demonstrative part is
affected The division of the peritoneum into
these two parts is based upon a relatively free or
scanty cerebro spmal nerve-supply The anterior
and lateral parts of the abdomen are lined by
peritoneum well supplied by somotic nerves whicJi
bring about brisk reflexes The pelvis and median
portion of the posterior abdominal wall lm\ e a scant}
cerebro spmal supply, and in consequence irritation
of these parts causes minimal reflex symptoms ^

Toxic symptoms are nearly always Hte m onset
There is indeed an inverse relationsJiip between
the two groups, since se\erc toxsemm diminishes
the sensibility of the reflex arc It thus follows
that when a non dcmonstrati\ e part of the peri-
toneum (e g the pel\ ic) has been pnmaril} affected

‘ See further details m Z Copea Clinical Uesfarehes m Acitle
^■ibdainirtal Diseasr p 21 el $eg (O^ord Medical rublicaUons)

15

^Reflex
I Toxic

22G DIAGNOSIS OF THE ACUTE ABDOMEN

reflex symptoms may be minimal througliout, for
oncoming toxaemia diminisbes the reflexes from tlic
demonstrative part as it becomes progressively
involved. Unless this fact is appreciated it is easy
to overlook a pelvic or central peritonitis until tlic
infection has advanced to a serious extent.

It ■will be noticed that two symptoms — collapse
and alteration of temperature — are included in both
groups. Collapse, by which wc mean obvious and
rapid depreciation of the circulation and metabolism,
may be seen either early or late in tlic course of
peritonitis. In the early stage it is a reflex symptom,
•whilst later in the courscof thcdiseasc it is the result of
absorbed toxins. Tiic early reflex collapse is usunlly
quickly recovered from, though occasionally toxic
collapse follows close on the heels of reflex collapse.
Early collapse is absent in those cases which have
an insidious onset and is less likely to occur when
the silent area of peritoneum is primarily involve<l.

Alteration of temperature is common in perito-
nitis, but is not sufTicicnlly constant or regular to
be of much aid in diagnosis. Early collapse is
accompanied by subnornml tcmjicratnre, whilst the
ingravescent stage of the disease is usually indicated
by fever of an irregular type. In the later stages
of peritonitis the temperature may be normal,
subnormal, or slightly clcvnte<l.

The early and reflex symptoms of peritonitis
may, lu Uic absence of initial collapsL\ he cxlreincly
equivocal. They arc more likely to be definite in
young persons u hosc reflex arcs arc normally more
sensitive, and conversely they may he insignififant
in old and debilitated patients.

Fain is the most constant symiitom. It may he

ACUTE PERITONITIS 227

confined to the local area of inflammation or
referred more generally over the abdomen. As the
peritonitis extends the pain-area also extends,
though the maximum pain is nearly always felt at
the initial focus. Tenderness is a constant feature
over any focus of peritoneal inflammation. Even
when rigidity is absent there is usually pain
felt on pressure over the affected site. Only t^vice
or three times have I seen this tenderness absent —
once or twice as the result of extreme toxaemia
dulling the sensorium, and once as the result of
extreme muscular rigidity which apparently pre-
vented transmission of the applied pressure to tlic
underlying inflamed area.

Vomiting is common at the onset of peritonitis, but
is usually infrequent until late in the case. The
later vomiting is usually obstructive in clmracter.

The change in facial appearance, though a guide
to the experienced, is something which cannot be
indicated satisfactorily in words. The white, drawn
face of initial collapse will tell anyone tliat some-
thing serious has happened, but collapse is by no
means constant. In any case, the reaction from
initial collapse is so rapid and complete tliat the
facial aspect commonly becomes and remains
almost normal for a time. But there is usually an
indefinable yet perfectly definite aspect of counten-
ance in many persons who may present an other-
wise doubtful picture of peritonitis. TJie Hippo-
cratic facies present in late peritonitis is merely
that of extreme collapse.

Muscular rigidity is a common accompaniment
of the early stages of ]>critonitis, hiii only xohen the
part of peritoneum affected lies m the demonstrative

228 DIAGNOSIS OF THE ACUTE ABDOMEN

aiea It is best seen m perforation of a duodenal
or gastric ulcer, -svlierebj a large part of the demon
strati\e section of the peritoneum is irritated It
IS genenll> absent or but slightly demonstrable
uhen the peritonitis is limited to the pehis In
tliose cases in winch rigidity is present in the earh
stages the muscles relax as the peritonitis progresses,
until m the final picture it is almost absent Rigiditj
is also either absent or dilTicult to detect m fat
people with flabby muscles and in old and ucak
patients Rigiditj may be of slight degree m
some cases of pneumococcal peritonitis and in some
of the sloulj advancing infections due to tlie
bacillus coh and streptococcus
Ctd(uieou5 htjpcrccsthcsta is frccuicntlj seen in the
subumbihcal area of the abdomen in the region
supplied b> the tenth, cleaenth and tnclftli tlioiacic
nerves It is more frequently seen on the right
side Commonly it is limited to a narrou strip
abo\c each Poupart ligament
The toxic symptoms of periiomlis arc later m
appearance and indicate a more serious stage of
the disease An occasional intcrmittcnce of the
pulse IS often one of the indications of advauemg
peritoiutib ^Vs tlic infection imoKcs the aarious
coils of intestine they become paralysed and dis
tended, whilst the intestinal contents stagnate and
increasing obstruction results Poisonous sub
stances are absorbed from the stagnating contents
and secondary collapse results At tins stage true
obstructive vomiting is commonlv a feature, and
at this time will be noted the small running puhe
commonly described as indicative of peritonitis
Such a pulse is felt m the latest stages of peritonitis,

ACUTE PERITONITIS 229

ind not m the earlier stages when diagnosis is so
important

The differential diagnosis — It is not difficult to
diagnose a flagrant case of peritonitis, for the pain,
\omitmg, local tenderness and muscular rigiditj
uith fever sufficiently indicate the condition, but
mistakes are hkelj to be made either because the
symptoms are thought to be too slight or because
the} are atjpical The earl> symptoms are slight
and decepti\e uhen the part primarily affected
lies in the pehis or in some other relativel} silent
area of the abdomen , they are often atypical in
patients vho are old, debilitated, or \er} fot In
the late stages of peritonitis it is frequently fmpos
sible to differentiate from intestinal obstruction,
uhich de\ clops as a late consequence of peritonitis
\\ e u ould take one more opportunit} of emphasizing
that the condition of the pulse is no true guide in
diagnosing earl} peritonitis

The conditions Inch ma} simulate pci itonitis arc

Pleuro pneumonia

The colics

Intestinal obstruction

Internal li'tmorrhagc

borne nervous conditions eg tabes, h} stern

The differentiating points uiU be found enumer
ated in other parts of this book

PRIMARY PNEUMOCOCCAL PERITONITIS
By primary pneumococcal peritonitis is meant
that form of infection -with the pneumococcus in
^\hlch the peritoneal s}Tnptoms are the predominat
mg feature of the illness It is fairly reasonable to

230 DIAGNOSIS OF TIIE ACUTE ABDOMEN

suppose that the peritoneal lesion is nearl} always
secondary to some other focus m the bod>, but
when that focus is latent or of minor importance
it IS customary to use the above term
Blood infection without any ascertainable focus
of origin does occur, but more frequently infection
spreads from the Fallopian tube, or possibly from
the intestine The disease is mucli more common
in females under the age of ten

The symptoms \ary considerablj . They arc
those of peritonitis of varying grades of sc\ critj
One can with ad\antage describe three stages to
the disease — the stage of onset, an intermediate
stage, and a residual stage (Waugli) *

The stage o£ onset starts abruptly u itU abdominal
pain, aomiting, and fc\cr, wbicb miiy reach lOt® or
105® r In some instances there is noticeable
diarrhoea Frequently there arc to\ic symptoms
out of proportion to the local findings, and dchrimn
may be noted

The abdominal pain may be diffuse, but is usually
more definite in the hypogastnum The abdonunal
wall may be rigid, but more often is soft and there
may be but slight local tenderness

In the aery sc\crc cases, which are always
seplicTjmic for a time, death may occur within Uso
or three days

Tlie mtermediate stage corresponds to tlic forma-
tion of pus w ithin the abdominal ca\ ity . '1 lie Iomc
symptoms lessen, but irregular fc\cr persists, and
there is a gradual tumescence of the abtlonicii
(Waugh) Leucocytosis will be observed Ab

> See Proc Koynl Sor Med, 1021-5, so\ I, ClilMrcn

ACUTE PERITONITIS 231

dominal paiii m this stage is very slight, and the
continued fever and a painless tumid abdomen
may cause a suspicion of tuberculosis

The residual stage corresponds to the definite
localization of pus and the absence of all acute
symptoms save fever of an irregular type The
pus may be in the pelvis, or m the central part of
the abdomen, or c\en m the subphrenic region

The diagao5i9 in the first stage has to be made
from acute appendicitis This is sometimes very
difficult, but if tlie initial fever be high, if the
abdominal signs are rather indefinite, and especially
if there be slight delirium and troublesomediarrhcea,
one should suspect pneumococcal peritonitis The
condition occurs chiefiy in young girls, and some
help may be obtained by examining the vaginal
secretion for the pneumococcus, since Fraser has
shown that the Fallopian tube is the common route
of infection If there be any serious doubt it is
viser to lecommcnd exploration, since more harm
IS likely to result from allowing a septic appendix
to perforate than from exploring an early pneumo-
coccal peritonitis

In the intermediate stage the continued fever,
tumidity of the abdomen, and comparatn e absence
of abdominal pain and tenderness may lead to a
suspicion of tuberculous pentonitis or e\en typhoid
fe%e.r The history of onset, the palpation of any
enlarged glands or masses in the abdomen, or the
positive result to one of the recognized tests for
tuberculosis may help to diagnose tlic fonner;
whilst tlic absence of leucoc^tosis, an enlarged
spleen, and a positive agglutination test would
point to typhoid.

232 DIAGNOSIS OF THE ACUTE ABDOMEN

In the third or residual stage a definite SA^elling
%m 11 be detected in some part of the abdomen ; tins
IS a residual abscess, and may be m the pcUis or
upper or middle abdomen. TJic diagnosis in tins
stage has to be made from the other causes of
abdominal tumour and abscess The history of
the pre\ lous illness v.iU be of the utmost importance
in deciding on a diagnosis

It has been mentioned abo\c tliat pneumococcal
peritonitis may not gi\ c rise to the muscular rigidity
uhich IS usual Avith most other forms of acute
peritonitis I have knoun the combination of
abdominal pam, \omiting, and lav abdomen gne
grounds for diagnosing acute intestinal obstruction.

If there be coincident plcuntis or pericarditis
the symptoms of peritonitis may be entirely over*
shadoued In the early stages of a pneumococcal
pol>serositis it is often very difiicult to determine
the exact diagnosis, but if definite signs declare
themselves m the lung it would be inadvisable to
recommend opening tlie abdomen until tlicre are
sufiicient grounds for suspecting tlic presence of
pus If the thoracic condition Ins been success-
fully treated, but the patient does not progress,
special care must be paid to the abdomen, for the
absence of rigidity and the comparativ elj slight
pain maj allow a considerable collection of pus to
go unobserved Waugh draws attention to tlic
significant tumescence of the abdomen in these
cases

CHAPTER XIX

DISEASES WHICH MAY SIMULATE THE ACUTE
ABDOMEN

There are a number of diseases which either do
not need or positively contra-indicate operative
interference, which may yet cause symptoms very
suggestive of conditions for which operation is the
best procedure. In some cases the symptoms arise
from disease \Wtliin the abdomen, in otlier instances
the pain is referred to the abdomen from another
part of the body, e.g. thorax or spine.

GEKERAL DISEASES

It is not uncommon for abdominal pain and
vomiting to occur at the onset of some of the
specific fevers or of infiuenza, but in such the
general symptoms outweigh the local manifesta-
tions. Fever will be present at the start and the
general malaise is greater, while locally there will
not be found the tenderness or rigidity which sug-
gest intra-abdominal inflammation, and it is by
this discrepancy that the observer will be guided.
Occasionally the abdominal symptoms may precede
the general manifestations of fnlTucnza ; the pain
may be of a severe colicky type, and if accompanied
by vomiting may giv'e rise to a suspicion of acute
intestinal obstruction. The vomiting never tends
to become faiculcnt and soon the general symptoms
of influenza appear.

23 i DIAGNOSIS OD THE ACUTE ABDOMEX

During an epidemic of influenza one is more
likely to mistake an acute abdominal condition for
a simple influenza \nth gastric s> mptoms — a serious
mistake.

Diabetes. — Impending coma in diabetes is often
accompanied by se\ ere abdominal pain and \ omtt-
ing. There may also be some rigidit} and tender-
ness of the abdominal ivall The way is tlicn clear
for a misdiagnosis of acute inflammation 111111111 the
abdomen and, indeed, mistakes of tins nature have
been made

In order to aioid such mistakes the first step is
the routine examination of the urine for sugar If
sugar IS found the presence or absence of diacctic
acid must be determined If a ketosis is found
the abdominal symptoms and signs must be \cry
carefully obsen cd and appraised If tlicrc be nni
serious doubt about the di.agnosis immediate stcjis
should be taken to treat the ketosis b> administra-
tion of insulin With glucose. If the abdommd
symptoms are entirely due to diabetic condition
tliej 11 ill \cTy speedily subside under this treat-
ment If thej do not sliou signs of subsulmg the
surgeon can be sure that there is a senous inlra*
abdominal condition present

Typhoid fever is sometimes accompanied by
abdominal pain and local tenderness, cspcciuUy
m the right iliac fossa (sec Chapter V}

\n \Topit:a\ zivuscs

scicre abdominal pain, but the t\pc of ft\cr and
an examination of the blood casilj enable out to
diagnose

Tuhercolous pentomtis ma> cause lague ab-
dominal pains, distension of the abdomen, and free

DISEASES WHICH MAY SBIULATE 235

fluid. These symptoms may occasionally give rise
to the opinion that there exists some acute abdom-
inal condition. The gradual onset of symptoms,
the tumidity of the abdomen, the lack of rigidity
and tenderness, and the presence of tubercle else-

Fio. 30 — Diagram to show mctliotl of diHerentiating between riglil-
sided abdominal pain of tfaoracie and abdominal origin. (Pressure
from the left side causes pam if abdominal m origin.)

wlierc in tlic body may be sufficient to lead to tlie
correct diagnosis.

It must be remembered, however, that intestinal
obstruction and perforative peritonitis sometimes
occur in the course of tuberculous peritonitis, and
these demand operative treatment. Sometimes
when the ileo-crccal region is extensively involved

236 DIAGNOSIS OF THE ACUTE /VBDOMEN

in the tuberculous process, the gut may be adlicrent
in the iliac fossa and the simulation of appendicitis
may be very close There may also be supcrlicial
hyperesthesia, but in acute tuberculous peritonitis
this IS usually more extensive than m appendicitis,
reaching occasionally well above the umbilicus

Food poisoning may give rise to abdominal pun,
vomiting, and collapse There is a serious pitfall
here Many patients who have a ruptured appendix
or stomach attribute the trouble to the eating of
some particular article of diet One maj tlicre
fore miss a condition needing surgical intervention,
just as one may think an operation necessarj when
there is no need for mterf'^rence In food (or
ptomaine) poisoning the symptoms usually follow
definitely after eating some article of diet suspected
to be tainted Frequcntlj several jicoplc arc
simultaneously attacked In an> case, tliougli the
general sjmptoms are similar, the local abdominal
condition is unlike that of peritonitis (no ngidit>)
or severe obstruction (absence of fTCulent v omiting),
and there should usually be no difiicult^ in diagnosis
if a careful watch be kept upon the case

BL00D.DISEA5ES

The only blood disease winch I have c\cr known
to cause simulation of acute abdominal disease is
spleno medullary leukemia The patient gave a
histor} of prolonged indigestion, had suffered rc
cently from irregular fever, and with an ana.imc
appearance presented alsogreat tenderness, rigidit},
and dullness m the left lijpochondrmni so llml the
simulation of subphrcnic abscess due to a leaking
ulcer w ns rather close A Icucotj tc count, how c\ cr,

DISEASES WHICH MAY SDIUL\TE 237

slio\\ ed 240,000 white cells to the cubic millimetreand
the true condition as recognized The acute local
reaction was due to tension and threatening rupture
of the spleen, for spontaneous rupture took place
sliortly afterwards

Attacks of severe abdominal pain accompanied
by vomiting (and sometimes diarrhcea) occur in
some cases of pernicious anaemia, but seldom gn e
rise to serious difficulty m diagnosis

THORACIC DISEASES

Pleurisy or pleuro-pneumoma — Either of tliese
conditions may cause abdominal pain and rigKht\ ,
and ma> be accompanied by vomiting In
some cases it is quite easy to distinguish bj the
signs present in the chest, but in children m whom
the thoracic signs arc often late m appearing, and
in some cases of diaphragmatic pleurisy in which
few signs may be found, diagnosis is e\tiemel>
difficult I have discussed this subject more fully
elsewhere,* but a summary of the mam differential
points will be found on p 238

An additional test is illustrated in Eig 30 If
the pain be unilateral and of abdominal origin
pressure from the opposite side of the abdomen
towards the affected side will cause pain, wliilst if
the pam be referred from the thorax no pam is
caused by pressure

Acute cardiac disease frequently causes symptoms
referable to the abdomen Epigastric pam and
tenderness are common when the liver is congested
and swollen from back pressure, \omitmg is not an

* Chmenl Itesrmches tn Amte Abdomtnal Disease (Oxford
Med cal Pubbcalions)

COMPARATIVE TABLE OP SYMPTOMS IN ACUTE
ABDO’\nNAL AND ACUTE PLEURVL OR PNEU-
MONIC LESIONS

ABDOMINAL.

PLEDRAL OR PNEUMONIC

Previous History —

Indigestion

Common cold or ‘ chill "

Colicky pains

Constipation

Lsposure to infection

Diartheea

Oasef—

Acute without fever (except
pyelitis)

Rigor unusual (except pyehtu)

AcutO with fever at start

' Rigor common

% onutuig usual

1 \omiting le&s common

Pain often shifts downward

; Pam thoracic as well os abdominal

examination

{ Cltc«k-f iluslied
Al» uasi ■wording
Somcttmes hrrpo* on I p*

SLin bo hot and dt>

p

1 tes* eoinmonJy ngid

Common, o«pcciaIl} Wow cinvi
cl«

Appearanef—

\ane<3 from normal to ob
donunal ’ facies
Skin--

CoUl OT clammy ot normal

PoUe and Respirallon—
lio sure guide
Abdominal wall>-

Uaf be rigid.

Phrenic sboulder-palo—
Common, but aeldom below
claviclo

I

J

Skin bjrperiesthesla—

Common

Psoas test —

Often pos tire
Obtnrator test—

Sometimes (rorely] positive
Testicular pain —

Sometimes present
Rectal cxamlnatloo —

May elicit lendemcas or
demonstrate lump
ExamlaatloD of chest —
Frequentlj si gbt rubs m npper
Bodominal lesions

Bare and never below le\el of
navel

Always negative
tlwtfja negative
Never present
Negative

May bo « rub or dullnm* or
bronchial breathlno but some
times nothing Off into at onset ]
I of symptoms ,

In eases which still remain doubtful after careful clinical cvaminntion
asmall incision to tlm ri^ht of navel Under inorpl mo and local aifciihc) a
should Lc iiiaiic

S33

DISEASES raiCH MAY SIMULATE 239

infrequent symptom in cardiac failure, and severe
collapse may usher in an attack of pericarditis or
accompany acute cardiac failure I have on occasion
been called to cases of endocarditis, pericarditis,
and angina pectoris which were thought to be cases
of abdominal disease Needless to say, in any case
of doubt, the circulatory system must be very
carefully examined. It is indeed seldom that any
doubt remains after one has measured the cardiac
and hepatic dullnesses, listened to the cardiac
sounds, noted carefully the character and rate of
tlie pulse, and observed if there be any venous
pulsation

The only case in nluch I have kno^vn any reason
able doubt was that of a man of sixty to whom I
^vas summoned in the middle of the night for n
supposed perforation of a gastric ulcer. The
patient had been under treatment for a twelve-
month for gastric ulcer uhicli caused frequent
attacks of indigestion Sudden abdominal pain
and collapse had supervened several hours before
I was summoned I found the patient fully
conscious, very talkative, but extremely distressed
and short of breath. No pulse could be felt at
either ^^rvst, nor could the brachials be felt to
pulsate The heart nas beating ICO to the minute,
and the superficial veins of the neck were pulsating
The iaec uss tender and eniarged do^in
to the umbilicus Pam was felt down the left
arm to tlie elbon . I diagnosed cardiac failure and
angina pectoris and refused to operate. The
patient died fi\c hours later, and a post-mortem
examination of the abdominal cavity shoned no
gastric ulcer and no penlonitis The thorax was

240 DIAGNOSIS OF THE ACUTE ABDOMEN

not examined, but it ^\as clear that the frequent
attacks of indigestion had been slight attacks of
angina pectoris The diagnosis of cardiac failure
would not have given rise to so much doubt if tlie
gastric lesion had not been so confidently diagnosed
previously.

Ordinary cardiac failure docs not cause true
rigidity of tlie abdominal Mail, though pressure on
a tender sm ollen liver may elicit muscular resistance.
With acute pericarditis, houever, there may be
true rigidity of the abdominal Mail, but this Mould
be unaccompanied by other signs of abdominal
disease With pericarditis also tlicrc may be
phrenic referred pain felt under the left cloMcle
The significant pain down the left arm in any
form of cardiac disease may be lielpfiil m diagnosis.

DISEASES OF THE SPINE OR SPINAL CORD

Acute osteornyehlts of the dorsal or lumbar lertehrce
may cause abdominal pain and rigidity, but there
will be great tenderness on pressure o\er the
affected part of the spine mIhcIi Mill drau attention
to the origin of tlie pain

In children acute abdominal (cp.gastric or um-
bilical) pain may be consequent on PoiCs disease oj
the spine. The absence of abdominal signs Mould
naturally cause examination of tlic spine and de-
tection of the spinal disease.

Tabes dorsalis frequently causes sc\ ere abdominal
pain m the form of gastric crises. Tlie crises, tliough
more common m adults, also occur in cluldren mIio
are the subject of juvenile tabes The pains may be
\ erj' severe, and uncontrollable vomiting may occur.
The important point to rtmember is that the

DISEASES \raiCH IIAY SIMULATE 241

abdominal vail is not rigid in the inter\als of the
pain of a gastric crisis.

Ulien there is the slightest doubt about the
diagnosis, it should be made a rule to test the
pupillary reactions and the knee-jerks, so that the
mistake will not be made of advising an abdomen
to be opened when the pains are caused by tabes
dorsalis It must be recollected, hoi\e\er, tliat an
acute abdomen may occur m a tabetic subject, and
one should not hesitate to advise operation if the
local signs are definite A gastric crisis is most
frequently mistaken for a perforated gastric ulcer,
though careful examination should easily prevent
this ; a perforated ulcer has been sometimes misdiag-
nosed as a gastric cnsis simply because the patient
^\as found to be suffering from tabes dorsalis. It
cannot be too strongly emphasized tliat persist-
ing board-hke rigidity of the abdominal ^\all in-
dicates something more than a tabetic crisis.

RENAL disease

Serious disease of the kidneys may cause ura?mm,
vhich may be accompanied by vomiting and
abdominal distension. Thus intestinal obstruction
may be closely simulated. This may occur either in
acute nephritis, chronic nephritis, or in bilateral
cystic disease of the kidneys
If in every case of mtcsbnal obstruction one
remembers tlic possibility of uraimia, tlierc should
be no great difficulty in diagnosis by' considering
the differential points set out beIo\\ .

latestinal obstnicUotu Urseroiu simulating obstruction

Indication of renal failure ab Mavbe^erj drj, furrcil tongue
sent and great thirst

No albuminuria. Albuminuria of variable oinount

10

242 DIAGNOSIS OF THE ACUTE ^UBDOMEN

Intestinal obstruction. TJrstma simulating obstruction

Vomiting tends to become £cou> Vomiting not faiculent,
lent.

Ifobstniction low doivn. absolute Bonrels mnj* return flatus after
constipation of flatus and enema.
fjEces

May be history of subacute May be history of some surgical
attack of obstruction. or medical disease of kidneys.

No renal tumours. In cj'Stic disease bilateral renal

tumours found.

Blood-piessure may be normal Blood pressure likely to be much

raised, <

It is very seldom that the two conditions are
confused when once the possibility of urtemia is
considered.

RETTRO-PERTTONEAL CONDITIONS
When one considers that the majority of the
early symptoms of peritonitis arc reflc.x in chniactcr*
and that the nerve-endings constituting the afferent
part of the arc he for the most part in tlie sub-
peritoneal tissues, it is no vondcr that various
irritating lesions in the space behind the peritoneum
may closely simulate peritonitis. Retro-peritoneal
effusions, if considerable in amount, may also
displace the large bowel and cause obstruction.

The chief lesions occurring in the rctro-pcritoncal
tissues and liable to cause difficulty in diagnosis
(apart from acute pancreatitis) ore :

Rupture of aneurysm of aorta or any of tlie
big abdominal vessels.

Dissecting aortic aneurysm.

Retro-peritoneal Vntanorriiagc iTom injury uS
kidney, or spontaneous bleeding from renal
grow th.

Retro-peritoneal extravasation of bile.
Extravasation of urine into extra-peritoneal

DISEASES AVHICH SIAY SIMULATE 243

tissues from ruptured bladder, ureter, or
pelvis of kidney.

Pelvic subpentoneal infections

In the early stages of many of these lesions it is
extremely difficult, if not impossible, to diagnose
with certainty from ao mtra-peritoneal lesion, but
^vhen a sufficient amount of blood, urine, or inflam-
matory fluid has collected m a part which can be
examined diagnosis may be rendered more easv by
a sign pointed out by Joyce This sign, which is
dependent upon the fact that a retro peritoneal
effusion is not movable, consists m a sharp line of
demarcation between a dull fixed area and the
resonant remainder of the abdomen , it is of most
value in perirenal extravasations, and in such cases
the limiting line corresponds m position to the dis-
placed ascending or descending colon, whilst the dull
area occupies tlie loin and lateral part of theabdomcn
Rctro-pentoncal extravasation of blood fiom rup-
ture of an aneuiysm of the abdominal aorta or one
of the big abdominal vessels constitutes a grav c
emergency which can seldom be successfully treated
by surgerj. Diagnosis may be possible when the
patient has been known to be suffering from an
aneurysm. Sudden collapse and great abdominal
pam would naturally direct one to tlie cause In
the absence of any previous history, diagnosis is
often impossible The sudden appeaiancc of a
painful rctro-pcritoncal swelling following collapse
in a patient known to be suffering from severe
arterio-sclerosis might make one suspect the rupture
of an aneurysm In a patient suffering from malig-
nant endocarditis a mjeotic nncurvsm ma\ form
10 *

244 DIAGNOSIS OF THE ACUTE ABDOMEN

and rupture rctro-pentonealU vith the in\incdi'itc
appearance of a painful s^\clling and local ngidih
of the abdominal T\all In one such case I made
an erroneous diagnosis of permephne abscess through
not pajang sufficient attention to the obscr\ation of
a reliable obserier that the suelJing had not btcn
there the night before I saa\ the patient

Dissecting aneurism of the aorta causes aerj
sea ere abdominal pain, extreme collapse, and in
some eases rigiditj of the abdominal nail It is
therefore eas\ to understand hon it mn\ be mistaken
for perforated gastric ulcer With dissecting
aneurjsm, houe\er, the collapse is more lasting,
and the abdominal pain docs not abate as it docs in
the reactionary stage of a case of a perforated ulcer
Tlie absence of other characteristic signs of a per-
forated ulcer should sm c to distinguish
Se\ere mesenteric thrombosis causes symptoms
^e^^ similar to tliosc of dissecting nncurvsm and I
knon no nay of differentiating the two conditions
Retro-pentoncal c\tra\ asation of bile is usualh
diagnosed only on opening the abdominal caMty
It causes s>mptoms of subacute peritonitis

Pehic subpcntoneal infections, if acute, may
cause some mtra peritoneal irritation ^\c Iia\c
seen such symptoms caused by spreading gas-
gangrene of the \uha, and Joyce* relates a case in
uliicli scNcre abdominal symptoms folJoucd on the

the perirectal tissues. In such cases tlicrc is some
peritoneal irritation, the exact extent of uhicli can
often only be told by exploration

» See J L Joyce, Ilnlisft Jouniot o/ Surgery \ol xli, No 47,
p 51” el stq

INDEX

Abdomen, aa'jcullation of, 61
palpation of, 40

Abdominal cavity, determination of *
free fluid in, 45

Abdominal distension, 103, 104 I
causes of, 124 I

diaj^osticaignificancoof, 129, 130 j
in acute intestinal obstruction,
117, 124

m intussusception, 139
in \olvulus, li'il
ladder pattern, 123, 126
Abdominal facies, 35
Abdominal influenza, and append)*
eitia, 74

Abdominal mju/ie",
diagnosis of, S09, 210
diflorential diaroosis of, 210
bcmorrhsge following, 201
ihoek following, 203
types of, 202, 20J
Vbdoramal muscles,
anatomy of, 10

condition lo gastric or duodenal
nicer, 09

rigidity of, 40, 41, 01, 02,03
m Appendicitis, 02, 03. 70
Abdominal pain iSee Fain
Abdorainol rigidity, m peritonitis,
41,99. J’7, 228
AbclominsI symptoms,
blood diseases with, 230
general diseases with, 233
m pregnancy and puerpenom,
1C3-1C8

renal disease with, 241

retro peritoneal conditions with,

spinal diseases with. 240
tlioraclc diseases with, 237
Alxlominal tenderness, os symptom
of intestinal obstruction, 124
Abdominal tumour, 149
in intussusception, 137
Abdominal wall,

lojunos to, diagnosis of, 202 rf/r?
respirators movement of, 40
rigidit} of, 40, 41
in gastric or duodenal ulcer, 90
Abortion,

attempted, sepsis following, 165
threatened, causing abdotmnal
symptoms, 105

Abortion — eonititue>l

simulating appendicitis, 91
simulating ectopic pregnanej,

tubal, 172

with Ultra peritoneal bleeding,
178

Abscess following perforation of
appendix, 07
in abrlomtnal wall, 80, 87
psons So

Adrenalin mydriasis test for acute
, pancreatitis, 115, 110
Age, diagnosis m relation to, 23
I Aim ft&si, movement of, diagnostic
I aigmncanco of, 30

I Albununuria, 220
I Areenorrhcca ami ectopic gestation
174. 175

Amoebic colitis, 212, 213
Amoebic hepatitis, 211
symptoms and diagnosis, 212, 213
Amccbie ulceration, 215
Anatomy, importance of, m diag
nosis, 6, 15

Ancurjwm, of aorta, dissecting,

! abdominal symptoms of, 214
I Angina pectoris aimiilating aenlo
I abdominal eouditioti«, 239
I Anorexia, of appendicitis, 68, 60
Anus,

I prolapse of, 144

eimuJatingmtussusception, 1 40
Appondicitis. 52
abdominal influenza and, 74
scute, eotly operative treatment,
importance of, 62
mortality rate, 7
Signs and evmptomaof. 57, 108
simulating perforated gastric or
duodenal ulcer, 103
temperature in, 38
acute ill dronenhrosis simulatmg,
82

acute pyolitis simulating, 81
acute pyoncphrosissimulating. 82
age incidence of, 23
anatomical position of appendix
in relation to symptoms, 55
ascending conditions simulating,

79 80

carcinoma simulating, ^3
catarrhal. 77
<5

246

INDEX

App«ndjciti3— con/inu«f
cholecystitis simulating, SO, 187 I

eompbcatingpregnanej, 107 !

conditions simolating. 79, 1 16 |

diagnosis of, after perforation, 66,

before perforation, SC, 65, 66
diflerential, 74-93
mistakes in, S3
points in, 10

diaphragmatic pleurisy simulat
mg, 75 I

distmguished from acute pan !

creatitis, IIQ !

diverticulitis simulating 89
ectopic gestation simulating, 177
frequency of, 74
gene'al considerations, 32
hyperiesthesia of, 60
iliac, C7

conditions simulating, 84-89
intestinal obstruction simulating,
83

local muscular rigidity of, Cl '
movable kidnet simulating. 83
obetructionnfUeumsiinuIatuig,$9
order of occurrence of ejTuploms i
in 65 (

pain of, 57 63

painful and frequent micturition
dtmng, S20

pathologic^ condition in relation
to symptoms, 33
pelvic, G9, 8S

cooditioassiraulatuig, 79, 8$
hsmatocele simulating, l''l
m the female, 90 93
m the male, 8S-90
symptoms, 177

pelvic abscess following 72 |

perforated duodenal ulcer eimu i
lating, 84

pieriduodemtis simulating, SI I

pcrineplinc abscess simulating. 81
peritonitis following, 72, 93
positions of appendix m. 67 I

positions of cccum in, 71 |

psoas abscess simulating, 86
pulse in, 03 I

pyelitis sunulatmg, 166
signs and sj'mptoms of, 37
simulating a bilious attack, 77
simulating colic, 78
Btono m kidnc} and renal colic
■usulating, 83

surgical roeasurce necessary for, 6

symptomsof, after perforation. €6

order m occurrence of, 05 .

icmperature in, 63

Appeadjeitis— conrinued
testicular sjTnptoms of, Cl
tuberculous conditions s mulat
mg, 86
typhoid, 76
typhoid simulating, 70
typhoid ulcer perforation simula-
ting, 90

ureteral calculus aimutatmg, 63.
DO

vomiting during pr^naney sim
uiating, 164

vomitmg, nausea andonorexiaof,
29-31. GS, 50

AppendiculoTCojic, 78. 19S
Appendix,
afaaeess of, 67

ascending, conditions associated
witli, 70, 80

iliac position of, conditions associ
Btcd with, 79

inilained, in a femoralhcmisl sac,
100

local deep tenJernm over. 39
obstruction of lumen of. 53
pelvic, perforation of, 70, 71, 72
rupture of, 70, 71, 7S
peWie position of, conditions
associated with, 79
pcrforalcti ascending, diagnosis
of, 80

perforated, pathological condt
tions, 66

time of onset of, 23
positions of, 33, 07
rupture of, 53, 31. 66
various possible posit lonsof, 33
Appetite,
loss of. 31

It) appendicitis. 39
Attitude in tiCii, 36
Auscultation of abdoincn, 51

Bed, attitude of patient in. 36
Dile^uct, rupture of. 192
Biliary cohe,
cause of, 198
diagnosis of, 100
pain of, 17, 26, 27
avgns and •yinptom*, 40, 109, 107
«malaliiigehoIec>Blitu, I'i2
simulating perforatwl giutnc or
duodcnel ulcer, 1 (h>

Bilious attack, appendicitis Simula
ting. 77
Bladder,

acute distension of. 221
injury to, 205
niplure of, 20S, 210

INDEX

247

Blood and mucus in stools in
intassusception, 13G |

Blood pressure, estimation cf, in I
diagnosis, 50

Blood stream, infection carried by,
to peritoneum, 323
Bowels,

condition of, as diagnostic aid, S2
,^ee also Intealmea

Ciecal dyspepsia, suaulating appen
dicitis, 64
Cjccum,

carcmoma of, signs and s>n>p.
toms, 8>

gaseous distension in appcndi
citis, 64

in amoebic dj "entery, 213 214
m intussusception, 138, 130. 143
positions of, m appendicitis. 71
Cancer,

of largo botvel, I47--150
of tbo colon, 147-150
eimulating appendicitis. 87
Cardiac disease, with epigAstrie
pain and vomiting, 23?

Cervical nerves, nam m region of,
13, 14

Chest alTections, with acute obdom
inal symptoms, 237
Chest, examination of, 49
Childhood,

intestinal obstruction in, liO
intussusception m Set Intus
susccption
Cholecystitis, 187

oppendiCitisBimulatcdbj.Sft, 15K>
biliary colic simulating, 192
characteristics, 187
conditions simulating, 190
contents of the gall bladder in,
187 I

duodenal ulcer simulating, 101
differential diagnosis of, 190
hepatitis with, 193
. pain of. !>0, 81, 18S. 100
ricuhtj in 189

signs and symptoms, 80, ISO, }

189, I

simulating acute pancreatitis, 1 lb |
simulating amcebio hepatitis, 213 \
simulating appendicitis, SO |

surgical measures necessary for, S j
vomiting of, 188 ,

Cliolera sicca, 217
Colic,

appendicitis simulating, 78
appendicular, 78
biharj, lOo, 192, 108, 199

Colic — continued

simulating acute pancreatitis, 110
cause of, 16, 17, 101
diagnosis of, 106
diagnostic significance of, 17
gastric, 201

general observations on, 101
grave nature of, 17
mtcstmal, 78, 196, 107
lead, 197
pancreatic, 201
reflev parnly “m of, 1 74
renal, 106, 190, 20i> 210
signs and symptoms, IDt-197
simple, diagnosis of, 140, 142
simulating intussusception
142,143
uterine, 200
See aJeo Pam «

Coho mtussuscoption, 133
Colitis,
amccbie, 213

diagno><is and symptoms of, 142
simple, signs and symptoms of,
142

simulating intussusception, 142
aimulatiog large-gut obstruction,
153

trnumotic, 203
ulcerative, 153
Collopso, 18, 21. 36
abdominal cause of, diagram
illustrating, 103
ofintestinal obstruction, 121
Colon,

ascending, carcinoma of, simulat
ing appendicitis, 83
briosiDg of, 205
cancer of, 147-150
gaseous distension in nppendi
citis, 61

pelvic, diverticulitis of, simulat
mg appendicitis, 80
pelvic, intussusception of, in old
people, 140

reflex paralysis of, simulating
inteetinal obstruction, 161
rupturo of, 203
Constipation,

as diagnostic aid, 32
MBign of intussusception, 139
as symptom of intestinal obstruc-
tion, 122

in eanror of bowel, 149
in choleeyi'titi-i 189
m intestinal ob-,lniction, 122
Cullen’s sign, 1S3

Cyanosis m ocuto parcrentitis, 107,
115

248

INDEX

Dance, signs de, 139
Death m acuto abdominal cases,
peritonitis the commonest
cause of, 223

Decidual cast, passage of, 176
Dermoid cjst complicating puet
penum, 167

Dietetic coma, simulating acute
abdominal conditions, 234
Diagnosis,

abdommal muscles m, 10
age of patient in relation to, 23
anatomical knowledge in, im
portanee of, 8, 15, 1C
bowel condition as oid to. 32
delay in, danger of, 5
early importance of, 4, 6
errors in, due to imperfect ana
tomical knowledge, 8, 10. 14
examination of patient in, method
of. 3S

examination of peh ic cavit} io.46
form for, 22

general appearance of patient »Q,
39

hyperxethesia as aid to, 18. 42
liver dullness in, 44
method of, 21 34
muscular rigidity in. 40
nausea and loss of appetite os
aids to, 31

pain m relation to. 1. 2, 2S
post bistOTV of patient in. 33
principles of, 1
pul-o in, 7, 8. 37
respiration rate in. 38
temperature os aid to 3S
tongue asaxl to, 39
urino examination in 49
\omitmg ns aid to, 27
Diaphrogm,

pnin in, 12, 13. 14

abdominal conditions asso-
ciated with, 14

rigidity of, how demonstrated. 10
viscera m relation to, 15
Dnplirngmatio ptcunsj, 101
simulating appendicitis, 75
. sjmptoms, 7'>

Duirrhcca, appendicitis and. 66
Diarrhma m pneumococcal pcn»
tonitis, 230, 211

Diastase, urinary, increased, m
acute pancreatitis, 115
DwiUctwis. 219
Dll crticulitiK

signs and sjmptorn*, 69, I'M)
simulating appendicitis, 89
Douglas’ pouch, tumour m, 183

Duodenal obstnielion bj cicatrized
ulcer, 123
Duodenal ulcer,

acute appendicitissimulntmg, lOS
acute pancreatitisnronlating. 107,

cholecystitis simulating, 101, 19j
gastne crises simulating I Oil
inflamed, Bvmptoms of. 19|
intestinal obstruction simulating,
108. 109
pain of, 25, 101
perforated, 94
diagnosis of. 13
diflerentjnl diagnosis, lOI-ItO
general eonsidemtions, 01
eifflulating appendicitis, S(
signs and sj mptoms of, 91-101
pleuro-pneumoniasimuInting.iO?
rupture of eotopiegcstntion siniti
lating.lOO, 110
Duodenum, rupture of. 208
Dysenteric ulcer, 211, 216
D^atuenoiiheea,

Jiagnostio signifleanro of, 33
pain of, 300

simulating appendicitis, Di
spasmodic, 201

Djspnora in acute pancreatitis, 111

Cctopic gestation. HI
acuto abdominal symptoms Ae
coinpftT»>ji>p Tuptim' of, l“3
appendicitis Simulating, 17?
diiTerentiaJ diagnosis of. 177
liiematocole complicating, 18')
Irregular menstruniioii In, 1*1.181
positions of, 171
retroiertod grand uterus Siiim
lating, 181

rupture of, 10'), 172, 173
sicnulating appendicitis, 01
eurgical measures iieecwwj for, 5
s} mptoms and diagnosis, ITJ-IS]
wilhauboeuto hiGmorrIinge, 189-
181

Cmctino lij drochloridc, lu ammbio
hepatitii, 212

Cntcnc intussusception, 133
Lnteritis. simulating intu-xHUscep
tion 149

Entero colic intussusception, 133,
I3(

Enterocolitis, 142
Fntecospasm, 106, 197
Epigastric pntn. 29, 201
following foo<l, 33
in acuto pancreatitis, 113
In appen<iiritis, 57

INDEX

219

Epigastric rigidity m acute pan
creatitis. 113

Epigastnc tumour m acute pan
crcatitis, 114
Exsmmation of patient,
abdommal, 30
prmciplea of, 7, 8
routine, importance of, 7, 10

Facial expression diagnostic signifi
cance of, 35
in peritonitis, 227
Fades llippoemtiea, 104 227
taecal fistula, 120
Fseces,

m intestinal obstruction, 122
m mtusausception, 136
in peritoneal cavity, 216
Fainting,

abdommal conditions causing, 24
diagnostic significance of 24
Fallopian tubes m relation to pneu
xQococcal peritonitis. 231

Fevei, ol appentbcitis, 03 Ste also
Temperature
Fibroid, 167

simulatmg appendicitis, 92
subpentoneal.iimulatingstrangu
lated liomia, 158
riatulonce,

appendicitis and, 6G
cause of, 10

Iluid m abdommal cavity, condi
tions of occurrciico of 45
determination of, 45
Food, pain following, 33

poisoning, with acuto abdominal
symptoms, 23lj

1 notion sounds in peritonitis, 51

Gall bladder,
gangrene of, 187
local tenderness over, 188
rupture of, 1D2
Call stones, 187, I8S,

acute pancreatitis and, 112, 114
diagnosis of, 33

obstruction duo to, frequenev of,
119

simptoms cau«c<I b> gallstone
obstructing the intestine, 131,
132

pamdueto 188

Gangrene m intussusception, 134,
135

Gastric colic, 201
Gastric crises,

diagnosis and symptoms, 109
of tabes dorsalis, 240

I Gastru! CTL«e-i — eontmiud

simulating gastric and duodenal
ulcer, lOG

* Gastric juice, vomiting duo to flow
of, 28
I Gastric ulcer,

acute pancreatitis simulating,

, 105,110,117

' ago incidence of, 23

appendicitis simulating, 108
ectopic gestation simulating, 109,

no

mtestmal obstruction simulating,
108 109

pam of, cause of, 14
I perforated, 94

' appearance of patient witb. 30
complicating pregnancy, 167
conditions simulating IOj 110
diagnosis of, 104
differential diagnosis of, IOj-
110

general considerations, 0 1
liver duilnoss in 100
pain of 97
peritonitis with, 102
primary shock of, 00, 07, 105
I signs and symptoms, 95

I stage of reaction 90,07

temperature m, 38
rupture of, with formation of
Bubphrenio abscess, 110
I shock of. 17, IS
Gastritis,

appendicitis m relation to, 66
simulating ectopiopregnancj , 177
Castro intestinal e^mptoms of
I pyonephrosis and hydrone

I phrosis, 219

Genito urinary symptoms, acuto
I abdominal disease with, 21S

Gestation eao rupture of, 173
173-180

I Glycosuria in acute pancreatitis 115
Graafian follicle, lismorrbage from,

I 180

Gravid uterus, retroverted,

I causmg acute abdommal sjinp*
toms, 16(, 174

simulatmg ectopic pregnane}, I8t
] 185

I Hsematocele,

complicating octopio pregnancy,
ISO

diagnosis of 182

pelvic, conditions simulating, 18t

pelvic following tubal nipture,

250

INDEX

Ilsematocfle-— eonJinwcd

urinary symptoms of, 220
signs and symptoms of, 180-182
simulating appendicitis, 1S4
H»raatona,io\lowmgT«ial 60110,220
Haimorrliege,

duo to abdominal injune*, 204
intra-abdominal, 21
intra-pentoneal, 178-180
uterine, ISO. 181

Heat-etrolvo.gastro mtestmalsyinp
toms, 217

Henoch’s purpura, 144, 145
Hepatic abscess, 215
Hepatic resonance, area diagnostic
of perforated gastne or
duodenal ulcer, lUO, 101
Hepatitis,

aerompanjJTJg ehoJecyst/ti<, IM
nmeekie, 211-214
Hernia, 155-162

cause of death from, 7

femoTal{«iraagulated), 15S ISO

lanamod, 150, 15?

inguinal (strangulated), ISO. fCO

mortalitj rate, 7

neceasit) foreurgical treatment. 1

obturator, 102

painful, 153 ISO
Richter’s, 128

strangulated, conditions auou
fating, 157, 16S

genera] observations on, 118,
119 155

aignaandsjmptonisof, 155, 150 |
treatment of, 160
tceatment of, 7, 166
□mbilical (strangulated), 160, 101
sentral, obstructed and atrangu
lated, 162

Hcmial openings, e^atnination of,
39, 40

Hipdisoas!, tuberculous simulating
appcndiciln 86

H>drorelo of the coni, simulating
hcmin 137
II>dronep)iroais,

acute, simulating appendicitis, 82
acuta abdominal symptoms vitb,
218

signs and a) mptoms, 82
Ilydrosalpmi,
simulating appendicitis, 91
torsion of pedjclo of. 170
Ilypcraisthesia,

diagnostic signiOcanco of. 18
in appendicitis, 42. 57, 00
in peritonitis 228
method of testing, 41, J2

Hypochondnac pam. cau'csof, 186
right, following food, 33
Hypochondriac tenderness, right,
117, 193

Ilypogaslnc tendenift'S m ectopic
gestation, 17G

Hypogastnum, pain in, 17, 20, 108,
230

IIeo.esecal glands, tul>crcutous
signs and symptoroa, 85
etmalating appendicitis, 85
Iloo eseeal junction, caremoma of.

sim^aung appendicitis, 85
Iloo cscal lalio, failure of. 31
Ileo ciecal \ olvulus, 1 50, 1 52
Ileo-cohc intussusception. 133
Ileum, obstruction of, 124, 155
simulating appendiCftK, 89
Ileus duplex, 73
Iliac appendix. 67
Ibae fossa, ngbt, pam in, 26
Iliac glands, mflanieJ, simulating
strangulated hernia, 167
Iliac region, right, inflammatory
lesion of. disgncsii of, 18, 29
IliO psosls rigidity, 44, C9, 69
m appendjcitis, 00
Ilio-psoaa test, 44
Indigestion.

aMommal pauu dMenhed as,
33

appendicitis in relation to, 50
' Infancy, intestinal obstruction in,
U9

Inflammatorj lesions, localization
of. 16
Induf-nzB.
abdominal, 74

simulating acuio abdominal eon
dition8,233

Inguinal glands, inflamed,
simulating femoral hernia, 15't
simulating strangulated liernta,
157

Inguinal swellings, 153, 156
.See afro Hernia

Inguinal testis, torsion or inllam.

mationof. 157, 168
Injuriee,

diagnosis of, 29’> SIO
tJ7>cs of, 202, 203
Intestinal colic, cause, diagnosis,
and sjTnptoms, 190-103
Intestinal obstruction, 118
abdominal disteation in, 1 2<
tendernt*<« in. 12t
acute and chronic forms. 120. 1 '0
acute pancreatitis simulating, 107

INDEX

251

Intestinal obstruction — continued
age incidence of, 23
causes of, 118, 119
chronic, 120

complete, types m which seen,
125, 127

constipation as syroptom of, 122
diagnosis and svmptoms of, 103.

109 121-132
diSerential diagnosis, 152
distension, 88

gall stones causing intestinal
obstruction, 125, 131
general obserratioRs os, 118, 119
in infancy and childhood, 1 19
large gut type, 126, 127, 132
difierential diagnosis of, 152
mortahtj rate, 7
operative mortality of, 120
paiii of, 121 , 127

polMc appendicular suppuration
causing. 73
pemtalsis of, 125
primary shock or collapse of, 121,
125, 126
relief of, 120
rigidity in, 109

simulated by embolism or throm
bosia of mesentenc ressels,
130

simulating appendicitis, 83
simulating perforated gastric or
duodenal ulcer, 103, 109
amatl typo, 123 129
conditions simulating, 129, 130
Bubocute, symptoms, 149
symptoms, 120-125
temperature in, 39
tjpesof, 125-123
ursmio simulating, 241
vomiting of, 27-31, 121, 122
See alia Intussusception. Cancer.
Herma, Volvulus, etc
Intestinal pain,
causes of, 10
due to rupture, 206, 207
examination of, 25
severe, diagnostic signiOcance of
207

Inteetme, large,
cancer of, 147-150
colic of, 197
rupture of, 205, 206
tuberculousstncturo of, 119
ulceration of, symptoms of, 148
volvulus of, characteristics, diag j
nosisand8ymptom8,l60-152 {
Inteotme, small, oWruchon of,
diagnosis of, 128-130

I Intussusception, 123, 133-146
acute, diagnosis of 123, HO
1 age incidence of, 23, 133
I cause of, 135

conditions simulating, 140, 14"

I diagnosis of, HO

distension as symptom of, 127
general observations on, 133
in childhood and infancy, 133
I of pelvio colon in old people, 146
I poaitionofcsscumm, 138, 139,143
signs and symptoms of, 127,
135-139

subacute and chromic 145
I tumour in. 137. 133
' types of, 133, 134

vomiting in cases of, 31

^ Jaundice,

and cholec) stitis, 139
hepatitis with, malaria causuig,
213

in acute pancreatitis, 108, 114
Jejunum, obstruction of, 155
Joyces sign, 243

I Kidney,

I contusion or rupture cf, 204
disease of, with acute abdominal
symptoms, 241

movable, simulating appendi
citis, 83

painful swelling of, 213
polycystic disease of, 219
stone in, simulating appendicitis,
83

Knee jerks, 241
examination of, 49

Lead colic, 1D7

Leucocytosis. in amccbic hepatitis,
213

m primary pneumococcal perl-
iomtia, 229

inspleno medullary leukicmis, 236
Leukxmia, splcno medullnry, simu
tatmg acute abdominal
disease, 230
Liver abscess, 215
Liver-dullness, 207
diagnostic signillcance of, 44, 100
dinunutionor absence of, 100, 207
Liver, enlargement in tropical
climates, 212

Locwq'b test in acute pancreatitis,

116

Lom«,

ecchymosis of. m acute pan
creatitis, 114

252

INDEX

Loins— ccnJinued
pam ID, 12

pamfol BweUing of, 21S
palpation of. 4?, 41
Lumbar pam, 25

Malaria, causing hepatitis «)t)i
jaundice, 2I3
Menstruation,
as diagnostic aid, 32, 33
in ectopic pregnancj, 176, 184
irregular, 174, 175
Slesentenc vessels, embolism or
tbremboais 130,^44
eimulating intestinal obstruction.
130

Micturition, freqoent and painful
27. 80. 102, 202, 220
Morphine, misuse of, 4
Muscles, inioluntory, vomiting due
to etretcfung of, 38
Muscular ngidity, 40
condibons associated iriih, 4t
m appendicitis, 61
m peritonitis, 62, 227, 323

Narcotics, misuse of, 4
Nausea.

diagnostic eiguiQcance of, 3t
of appendicitis, 63
of intestinal olHtruction, 122
Navel, discoloration o(, in internal
hsimorrhage, 133
Nephritis,

rnth acute abdominal synptonis.
241

Nerves, abdoQunal, diagnostic sip.
m&canceof, 12

Obstruction, intestmal, SS e< *<<t , i
ns 140 150
Obturator hernia, 102
(Ibtuiator test, 0, 10

method of performing, 48
Omentum.strangulated, 83,124 ,I>i 5
torsion of, 33

Osteomjehtis, acuie, of vertebra*,
u ith abdominal pain, 240
Osteonijclitis simulating acute Sp
pcndicitis, 75
Ovarian ejst,

complicating puerperium, 167
simulating appendicitis. 01
symptoms, D1

with twisted pedicle, acute *j nip.
toms due to, 01. ICO

ram. 25. 191

aUloimnal general m tropics,
cau^osof, 214, 215

Pain— conlinucd
acute, 24

acute abdomioal, during preg.
nanej, 163

acuteness of onset of, 24
age ID relation to, 23
causa] diagnous, 2
0071*1001, 13, 14
charactec of, 2S

common sites of. diagram of, 105
dii^nostiesigmllcanceof. 1, 2, 25
diaphragmatic. 12-'14
during ectopic gestation, 175
during micturition, 27, iiO
during pregnane} , 1C3
during puerpenum, 167
earl} examination in cases of,
importance of, 4, 5
entenc, 196, 197
epigastnc, 25, 113, 201 237
exact timo and mode of onset of,
23

general observations and causes,
194

hvpochondnae, rniixes of, 136
li)'pegastnc, 17, 20
dunsgsctopie pregnancy. 176
indigestion in relation to, 23
m ruptured eeiopie inwlaliun,
referred, 110

in the shoulder, 14, 101, 138
tntropicaIcIiinate)>.2M,213 813
mtcetmsi, 25. 19^197, S07
cause of. 16
sigmCeance of, 16
lumbar. 25

narcotics (or, taisuso cf, 4
of acute pancreatitis, 117, IIC
of smcebio hepatitis, 213, 211
of appendicitis, 67
ofcacccc of colon, 149
of cholcc}'stitis, 8i>, 1ST, 188
of cholera uccB. 217
of gall stones, 188
of gastric ulcer, 97, 106
of deo circaJ olmtnicli 'ii, 8'»
of inflamed duodenal uher, 191
of intcetinaJ obstruction, 121. 124,
130, 127. M'l
of intussusception. 136
ofpentonitiB 226 227

of pneumococcal pcnloDitu 230
of ruptured intestine, f07
of ruptured tutnl aliortion, 179
of the colics, 19t-20l
phrenic, 113
pleuritic, 27
radiation of, 20
renal. 219

INDKX

253

Pam— conttniied ■ Pelvic abscess,

tespiration influencing, 27 from rupture of pelvic appendix,

routme examination of, 23, 23 ‘ 72

segmental, diognostic significance , symptoms of, 72, 73
of, 12 Peine appendicitis, 69, 70

IiypcrKstlicsia and, 41 | Pelvic cavity, examination of, 41

shifting of locali2ation of, 2C Pelvic)uematocele,173, 173-182,220

significance of, I, 2, 25 Pelvic peritoneum,

situation of, 21 ' palpation of, 99

special vaneties of, 27 subpentoneal infections of. 244

Btretchmg of involuntary muscles j tenderness of, diagnostic signifi

causing, 28, 29 ' cance, 47, 100

surgical measures for, indications Pelvis, fractured, conditions due to,
for, 6 208, 209

testicular, 27, 219, 221 | Percussion, supra peine, 46

thoracic, diagnostic significance Perforation of gastric or duoilenat
of, 14 I ulcer. 94 117

of abdominal origin, 237 Pericarditis, with pneumococcal

umbilical, 25 peritonitis, 232

vomiting in relation to, 23 Pericolitis, as symptom of cancer of

6ee also Coho I colon, 149

Pallor, diagnostic aigni/icnnce of. Periduodenitis, SI

33 . simulating appendicitis, 81

Palpation, I Pennephric abscess,

abdominal, 40 signs and symptoms, 84

of pelvio peritoneum, 99> 100 simulating appendicitis, 64

of the loins, 43. 44 i Peristalsis,

suprO'pelvic, 40 ' as sign of mtestmal obstruction.

Pancreas, anatomy of, 1 12 125

Pancreatic colic, 201 ' lo intussusceptiOD, 139

Pancreatitis, acute. Ill , Penloneal cavity,

association of. with gallstones, fecal flooding of, 210
X12 I freel3mJin,09

cjanosis m. 107. 116 movable dullness in, lOO

dvagncftva of, 1\\. H-T perfota.Uotv of gcaUveot duodenal

dyspncea m, 115 ulcer into, 84 94 99

ecchymoBis of loins in, ll4 I Peritoneum, paths of infection to,

epigastric pam and tenderness 223, 224

in. 113 I Peritonitis,

epigastric rigidity in, 113 occompanyinggastnoorduodenal

epigastric tumour in, Il4 ulcer, 99

gljcosuria in, 135 eousesof, 330, 224

jaundicein. 108, 114 collapse in, 22G

Loene's test in, 115 conditions simulating, 80

pam in, 113 liC diagnosis and symptoms of, 154,

pathology of, 1 12 223-229

shock in, 1 13 diifercntial diagnosis of, 229

simulated by or m o4l>CT condi- epigastnc, llC

tions, 116, 117 following appendicitis, 70. 71

sitniilating visciml perforation, foUowmgattomptcdabortion, 165

107 following perforation of appentlix,

s>nnptoms of, 112-110 87, 70 71

unnarv diastase mereased in, following rupture of dysontonc
115 ulcer, 213

vomiting ID, 28. 113. U* general, 223

Patient cau8C8andsymptorRsof,22l,225

appearance of, as diagnostic aid. local muscular rigidity of, 02, 63
35 mas.ke»l, OU

attitude in bed. 30 1 of mtussusception, 139

254

INDEX

Peritonitis-— ^»n^^nt/ed
path of infecti\o organisms m
223. 224

pelvic, during puerpenum, IG",
1C8

primary pDeumococcal, 33, 223-
232

diagnosis of, 231, 232
leucocytosia in, 23Q
sources of infection m, S30
stages of, 23C>, 231
symptoms of, 230, 231
pulse in. 37
reflex aymptoma of, 2o
respiration rate m, 3S
rupture of JQtestme causing, 203,
200

secondary general, 33
shock of, IS

signs and symptoms of, 1S4. 20G
simulating intestinal obstruction,
120

eimulatuig large gut obstruction,
1S4

spreading, 223

in late cases of appendicitis. 03
eynptoros of, 224-228
temperature in, 220
toxic symptoms of, 225, 226, 22S
tuberoulous, eimulating acute
abdomen, 234

simulating miussiuception, 145
visceral injuries causing. 303 205

Phlebitis of spermatic t ems. 158 221

Plirenic nerve, pain due to irrita
tton of. 12, 14

Pleural and abdominal symptoms
compared, 238

Pleurisy,

diaphragmatic, 71, 103
xritn acute abdominal symptoms,
75 237

Pleuritic pain, 27

Pleuritis, with pneumococcal pcri>
tonitis, 232

Pleuro pneumonia, double, 107
right basal, 191
signs and sj mptome of, 107
simulating gastric or duodenal
ulcer, 107

with acute abdominal s> mptoros,
237

Pneumococcal peritonitis, pnmar},
causes of, 230

Pneumonic and acute abdominal
symptoms compared, 238

Poljseroaitis, 232

Pott's disease, acuto abdominal
pain with, 210

Pregnane} ,

acute abdominal s} mptoins in, 163
conditions complicating, 164-16-8
spontaneous rupture ol uterus
during, 167

See alto Ectopic gestation
Prolapsus am di'.tinguKluHl from
intussiisi option ]4I
Psoas abscess simulating appendi
citis, 86

Psoas muscle, os diagnostic aid, 10,
38

rigiditj of, 44, 63

in appendicitis, C3, C9
Ptocnaino poisoning, symptoms of,
236

Puerpenum,

acute abdominal ay niptoms dur-
ing, 167

appendicitis complicating, 167
gastric ulcer complicating, 167
peliic peritonitis during, 167,108
pulse.

in abdominal conditions, 37
m appendicitis, 67 61
in cnolecystitis, 281
m diagnosis, 7, 8, 37
in gastric or duodesal nicer, 97
in pentonilH 37
locreased frequency of. 37
Pupils, examination of, 49
Pyelitis,

acute simulating appendicitis, 81
complicoting pregnancy, 166
symptoms and diagnosis of, 81,
82 ICC
ryonepluo«i8,

abdominal symptoms of, 218,
212

acute, simulating appenihulis, 82
j aigns and symptoms, 82
I Pyo pueumo subpbretucnbaco«s, 43
' Pyosalpinx,

diagnosis and symptoms, 161
simulating appendicitis, 5)3
siroulntmgcctopic pregnancy ,181
symptoms, 07

I Ibaitioii slain’ nflir i>crfon»tn/n « f
I ulcer, 5)7

' Roctal polypus, simulating intuf-
suseeption, 1 10
Rectal prolapse, 141
Recto obdominal examination,
melUed of, 4s

Rectum, digitol exainmnfinn of. 46
Rertus ruf tiiro of, 87

Kenol coleuius, signs and symp-
toms, 83

INDEX

255

Renal colic, lOG. 1,99. 200, 219
causes of, IQO, 200, 219
nature of the pam, 17
simulating appendicitis, 83
symptoms and diagnosis, lOG, 200
Renal contusion or rupture. 204, 205
Renal disease with acute abdominal
symptoms, 241

Renal symptoms of retro peritoiieol
lesions, 222
Respiration,
gasping, 25

Respiration rate, diagnostic eigmn
concQ of, 18

Respiratory movement of abdnm
inal trail, 40
Restlessness, 3G
Retro cjccal appendix Gl
Retro pentoneal eonditions sitnu
lating acute ahdominal (Ih
co.»o, 242

Rieliter’s hernia, 123
Kicdl s lobo, 187

Rigidity as a diagnostic sign, 40,
61. 02, G8, (19
, ilio psoas 44, C8
111 peritonitis, 227, 228
Routine examination,
abdominal, 39
age in relation to, 23
importance of, 19
method of, 21, 3S
necessity for, 7

Salpingitis, acute,

signs symptoms, and diagnosis,
93. 1C8

simulating appendicitis, 92
Segmental nerves, diagnostic sig
niGconce of, 12
Segmental pain,

diagnostic significance of, 12
hyperccsthesia and, 42
Sepsis, following attempt to produce
abortion, IGS

Septiccemia following attempted
abortion, 1C5

•Wierrcn *a appcncAx frrangiV,

Shock, 3C

characteristics of, 17

duo to abdominal injuries, 201

m Bcuto pancreatitis, ZJ3 ,

of intussusception, 13C i

pnmarj.l?

of gastnc or duodena] j>er
foiated ulcer, 05-97
of intostinal obstruction, Ijj,
125, 12G

Shock — continued
reaction from, 35
secondary, 18

signs and symptoms of, 203
vomituig in, 31
Shoulder pain, 14, 192, 193

abdommal conditions associated
with, 14

diagnostic significance of, 14,
16

ingostncorduodenal ulcer, 101
Sigmoid vofvidiu, 151, 152
Si^a, hj’perxsthesia at,
in appondieitia, CO
method of testing, 41, 42
Spermatto cord,

acute Itydrocele of, simulating
strangulated hernia, 157
thrombosis or suppurativa phle-
bitis of. 168, 22!

Spinal diseases,
simulating appendicitis, 75
with acute abdominal symptoms,
240

Spine,

Pott’s disease of, 240
rigidity of, 49
Spleen, rupture of, 217
Spot diagnosis, 3
Stomach,
contusion of, 205
rupture of, 205, 209
Siibphrenio abscess, rupture of
gastric or duodenal ulcer
with formation of, HO
Suprapelvic palpation and per
cussion, 4C
Surgical measures,

conditions necessitating, 6
importaneo of, 6

in acute appendicitis, neccrsity
for, 62

pain as an Indication for. 6
Symptoms, early recognition of, 2.
3. 6

Sj'iaptoms ui acute abdominal
and acute pleural or pneu
monie lesions compared. 23S

Tabes dorsalis,

gastric crises of, IOC 2(0

aimulaling gastnc or duodenal
ulcer, lOG

withocutoabdominal pam, 210
Temperature,

as diagnostic aid, 38
in abdominal Conditions, 38
in appendicitis, 63
in cholecystitis, 189

25C

INDEX

Temperature — conhnutd

u) gastric or dnodenal ukcr»39,97
m mtestinal obstruction, 39
m ruptured ectopic gestation, 39
Tenesmus, as sign of intussuscep
tion, 139

Testicular pain, 27, 221

diagnostic significance of, IS, 106
m appendicitis, G4
Testis,

inguinal, torsion or inflammation
of, 167, 16S

undescended, torsion of, 221
Thigh, flexion of, 10
Thigh rotation test, 48
Thoracic diseases, with acute ab
donunal a; mptoms, 237
Threatened abortion, 166
Thtombo«wof spermatic \e«w, 158,
2»1

Tongue, as diagnoetic aid, 39
ui urannia, 39

Triangle, Sherrcn a appemlcc, OO
Tropics,

acute abdoicmst conditions ui,

211

conditions simulatisg appendi
citii in, 79, SO
Tubal abortion, 172

with profuse intra-peritoneal
bleeding 178
Tuba] pregnancy, 171
ire OMO Ectopic gestation
Tubal rupture, 172
Tuberculous iteo-«9cal gliin«{-<. 83
Tuberculous mesenteric glands, 86,
197

Tuberculous peritonitis with acute
abdominal b> mptoms, 23(
Turpentine enexnata,
in constipation, 122
in diagnosis of intestinal obstruct
tion, 122

Typhlitis, amoebic 214
Typhoid fever,

aigna and symptonis, 7G, 77
simulating acute abdominal con-
ditions, 231

simulating appendicitis, 76
Typhoid ulcer,

^rtoration of, simulating eppen
dicitis, DO

signs and syroptoros, 90
rupture of, 21C, 217

nicors, perforated. Furgica] measures
necessary for, 5

Umbilical herma. obstructed and
euangulated. ICO-162

Umbilical pom, 26
Ursmia, 241

diagnosis and symptoms of, l3i\
163

polycystic disease cauimg, 219
aimulating mtestmal obs .ruction,
241,242

simulating large gut obstruction,

Biraulating small gut obstruction.
130

Ureteral calculus,
atgna and symptoma, 86
Simulating appendicitis, S3, S6,
00

Urethra, laceration of. 2u6
Urinary diaatasc, incTefts<*<l in acute
pancreatitui. 116

Urinary symptoms, acute aMoni
uial disease with, 218
Urination, painful and {rwjuoiit, 27,
ICd. 220

Unne, examination of. importonco
of, 8, 49, 82, |i>(l
Uterine coUe, 200, 201
Uterine fibroid, red degeneration or
nccrobiosia of, 167
Uterine aepais. 166
Uterus, pregnant, rupturo of, 167
reCroverted grai id. musing aUlo
minal pain, Ibt

Vaginal bleeding during ectnpie

f calation, 176 It'i
discharge, 168, 16*)

Vagino abdoiniael examination,
method of, 4S

Vonx, tUrombosM or aaplicnous,
169

Ventral licrma, diagnosis and aj mp
toms, lC(>-ltj2
VlBCCtO.

diaphragm in relation to, li
rupture of, 203, 20(. 204
Vi8t-«td in;une«, 202-210
peritonitis following, 206
Volvulus, 160-162

choractcnsttcs and Ij {«** of,
160

diagnosis of, 161, lli
frequency of, 119
signs and symptoms of, 128, 161,
162

V'orailiJig.

os diagnostic aid, 28
causes of, 27, 28, 29, 30, 31
conditions associated wul ,27, 28,

29,30, 31

INDEX

Vomiting — continued
Itequeiicy oS, SO
in acute pancreatitis, 113
in appendicitis, 30, 6G
in cholecystitis, 188
m intestinal obstruction, 31, 109,
121, 122, 129
m intussusception, 130
in peritonitis, 227
m strangulated hernia 107
in torsion and strangulation of
omentuin, 83

Vomiting— continued

iwAuse. of ttft vonnt, diogc.oatio
significance of, 31
o\arian cyst causing, 109
pain m relation to, 29
persistent, during pregnancy,
l&l
toxic, 29

X ray examinations in diagnosis
of abdominal di«(.ase, ^<1 61,
no 152 207